CBT training course questionnaire data analysis:

The adoption of the action learning cycle and development of an active practice development approach enabled the eventual delivery of the eight-day CBT course at eight localities across NSCCH. Each component of the initial

course (appendix 3) was fine tuned post development, by discussing it with the research team (identified NSCCH psychological therapy experts and academic partners). This cyclic process that continued throughout all courses was instrumental in the delivery and ongoing development of the course. The research approach taken developed and delivered in the spirit of an action research cycle enabled the development of a more rounded and robust programme. Going through the cycles at each location throughout NSCCH, focused the course to achieve the area and locality specific needs identified during the ‘MoodMatters’ staff survey, and pre-survey meetings, supported by literature and policy.

The questionnaires were analysed together so that it would be possible to identify positive, negative and neutral aspects of the whole data set. Each CBT training course questionnaire was designed to enable a mixed methods analysis (appendix 2). My initial impression of the findings was that by using a skills based model, delivered in a practice development paradigm, it was possible to train mental health professionals to evidence a change in their self reported readiness to use CBT skills in practice and also an increase in their self-efficacy as to this practice. The Cognitive Therapy Scale – Revised (CTS-R) (Appendix 8) developed by Blackburn and colleagues in 2001, at the University of Newcastle upon Tyne was used to place the components of the CBT course questionnaire into specific CBT practice themes. The analysis will be offered under headings drawn from the sub-sections of the scale and themed accordingly. This scale was based on an earlier one devised by Young and Beck in 1980, and designed to rate competence levels of a therapist, over twelve items, ranging from Item 1 - Agenda Setting and Adherence, Item 3 – Collaboration to Item 12 – Homework

setting, and is used by an independent rater. Blackburn et al, (2001) state that the scale has a good level of validity when used by raters that have been trained in its correct application. Research also shows that there is good inter-rater reliability within the trained cohorts (Blackburn et al, 2001).

Part A, Demographic Data Analysis:

The demographic details when analyzed showed some surprising results in certain areas e.g. ethnicity and gender of respondents, and some expected ones in others, e.g. professional background of respondents. The gender loading within the student population drawn from the adult mental health work force was 25% male and a rather larger than expected 75% female, this mirrors the trend in general health care provision across New South Wales, but was unexpected in mental health care provision due to the historically greater number of males entering the speciality. This result closely matched the gender make-up of the respondents to the 'MoodMatters' survey. The questionnaire enabled analysis of age of respondents. It was thought that in mental health care, especially nursing, there would be an older population of nurses in their 40’s, 50’s and 60’s. The data mirrored this to an extent with a total of 50 respondents being over 40 and 30 being under 40. This was a useful statistic to identify, as it would help with work force planning with a number of clinicians, mainly nurses close to retirement age.

The year of qualification data were unexpected; 35% of respondents had qualified in the 2000s, the next largest group 24% having qualified in the 1980’s, one would have expected from the age data recorded above that more staff would have qualified in the 1980s and 1990s. The ethnicity of the population taught was 87% white, compared to 3% black, 3% Asian and 8% other

(predominantly Aboriginal, Polynesian and Latin American), this mirrored the population demographic of Northern Sydney, an affluent predominantly white and Asian area, but not so much that of Central Coast a more ethnically mixed area. Over 50% of the student population were from a nursing background, either in-patient or community based, 14% Social Workers, 12% were Occupational Therapists and one clinical psychologist and 14% were other professionals. This other group was made up of therapists such as music therapists, dieticians, educationalists and consultant nurses (interestingly enough not classifying themselves as nursing staff!). No medics attended the training. 60% of the population had a first degree, 9% had a masters degree, 3%

had other qualifications such as post graduate diplomas and 22 respondents (29%), had either a certificate or a diploma. This percentage of the population would have been nursing staff qualified pre- 1986 who had not undertaken any further study or a small number of enrolled nurses who’s initial qualification is a diploma or certificate.

Part B, Qualitative data set:

There was not enough usable qualitative data recorded from the individual’s statements regarding their present level of CBT practice to provide a useful analysis. As stated earlier in the thesis this was thought to be a lack of psychotherapeutic content in core training, and limited psychological mindedness of core services. I have used student’s qualitative statements in the analysis of points C and D when they show CBT understanding and actual movement in their learning.

Part C, Your views about CBT:

This will form the bulk of the analysis chapter and be delivered under identified themes. Part C was split into two areas one with 20 questions the other with 13. Parts C and D of the CBT training course questionnaire had 33 questions in total. I will start with the analysis of the 20-question section of the CBT training course questionnaire; part C (see appendix 2).

Theme - An ability to use basic CBT Principles:

This theme is addressed in the questionnaire by six of the twenty questions (see appendix 2). Each question to an extent allows an insight to be gained into the respondents pre- and post- course completion views about CBT, its use with patients and their understanding of the underpinning theory behind the practice. Question one, four, twelve, thirteen, sixteen, seventeen and twenty fall within this category. The questions that sit within this theme were analyzed and showed that student’s views about CBT were affected by attendance and completion of the course. All of the questions pre- and post- ratings altered, but as a number only gained in agreement or disagreement scores, they will be discussed briefly, the others that had more marked changes will be discussed in more detail and the findings and implications outlined.

A number of graphs will be used to outline this move; others will be placed in the appendices (appendix 7). Question one was designed to gain an understanding of course participant’s belief as to whether or not CBT was too difficult to be offered to patients as a first line treatment. The NICE Guidelines (NICE, 2009) states that CBT should be offered as a first line treatment in a number of psychological conditions, notably depression, anxiety and more

recently psychosis. This question was included to see if there was a shift in respondent’s views about CBT being too difficult to offer to a patient as a core intervention of choice. The analyzed data showed that at the pre- course evaluation point, the majority of the respondents either disagreed or strongly disagreed with this statement, this increased at post- course evaluation.

The subsequent two graphs highlight student’s views as to why CBT is not offered as standard care to all patients across NSW Health. It was designed to ascertain views on the difficulty of applying CBT to clinical practice.

Question one. The Main reason patients are not offered CBT is because it is too difficult:

Graph 14. (pre course completion). Graph 15. (post course completion)

As you can see from graph 14 pre- course completion to graph 15 post- course completion there is a marked move in respondents’ views about the difficulty of delivering CBT in practice. 63% of the population pre-course completion that disagreed with this statement had risen to 97% post- course completion. This positive shift if translated to the application of CBT in practice would have a marked impact on the availability of CBT to patients across NSCCH.

Question four addressed the student’s ability to collaborate with the patient. This is one of the cornerstones of successful psychotherapy and CBT is no different in this regard (Beck et al, 1979). At both pre- and post- course completion the student population held the view that this was an important aspect of their patient focused interactions and they either strongly agreed or agreed with the statement. Although all respondents still supported the place of collaboration in therapy virtually all (99%) of them had decided that this was truly a vital component of therapy post course completion. This result although still within the strongly agree/agree category is important as it shows that the course strengthened the respondents views on one of the core tenants of CBT practice. It is thought that one of the therapeutic markers of CBT that helps to achieve a positive outcome at the end of therapy is the practitioner’s ability to engage with and collaborate with the patient (Morrison et al, 2004). Please see appendix 7 for all graphs not shown in the analysis chapter.

Questions twelve and thirteen (graphs 16 to 19) focused on the respondents’ ability to give informative advice and to feel happy communicating with patients regarding talking therapies. At pre- course completion a similar number of the respondents rated positively or negatively their levels of knowledge and skill in this area. At the end of the course virtually all (97%) of

the student population strongly agreed/agreed that they had the knowledge and skill to offer this aspect of CBT with patients. At pre- course completion 37% of respondents strongly agreed/agreed that they did not have the knowledge to give advice to patients about CBT. Over 60% of respondents agreed/strongly agreed that they were happy talking to patients about the effects of talking therapy. Both areas had risen to over 95% by the end of the course. These figures, if carried over to clinical practice, should see a greater number of patients being in receipt of evidence-based interventions than they were before.

This also, perhaps more importantly, evidences an increase in the respondents’

self-efficacy in their readiness to use CBT skills, see graphs 16 to 19.

The next four graphs outline respondent’s views of their knowledge and ability to apply talking therapies in clinical practice with their patients post CBT training course completion.

Question twelve. I do not feel I have the knowledge to give patients authoritative advice about talking therapies:

Graph 16 (pre-course completion). Graph 17 (post-course completion).

Question thirteen. I am happy talking to patients about the effects of talking therapies on their level of function:

Graph 18 (pre-course completion). Graph 19 (post-course completion).

Pre-course qualitative statements from respondents:

“My role is not a clinical theraputic role but, that of a liaison psychiatry role. So to participate in and be available for consultations with generalist clinicians in developing care plans for their patients” (Student 77).

“I believe I do these therapies yet I have not identified them as structured therapies” (Student 32).

"I feel a lot more confident. I have been using basic principles of CBT but not as yet in a structured way” (Student 77).

“More confident as in the past I would hit walls and blocks I feel this will not happen as I have many tools to implement & more structure to each session” (Student 32).

“Need more practice to feel fully competent, but I believe it will be an excellent tool for future work with clients” (Student 10).

“I feel comfortable to try talking therapies with patients. I think I’ll need practice to put it in a more structured manner, but I have the knowledge now to practice this” (Student 13).

“Nervous but able!” (Student 24).

“With increasing practice and application I contrive to be a confident practitioner” (Student 46).

The qualitative statements, from the same students, pre and post intervention show some marked improvement in confidence and belief in their ability to offer CBT to their patients. Most state that they feel they will be more

able to practice CBT after attendance of the course and some mention an increase in their confidence levels and knowledge by attending the course.

Although as stated earlier in this thesis the quantity of usable qualitative data was small, one can see a change in the limited examples above from the participants’ perspective. From data gathering point 1 to point 2 a number of the questions such as 'not sure' have been lost as the respondents were no longer 'unsure' post course attendance. This is true for a number of the graphs and shows positive movement regarding self-efficacy and readiness to use skills by attending the course. It also shows that the cyclic developmental nature of course delivery was achieving it aim of introducing respondents to CBT skills, one could also ascertain that the respondents input to course development by regular informal evaluations was fine-tuning the course for each subsequent delivery.

Question sixteen 'my instinct/intuition/experience is as good at assessing a patient as any outcome measure' was designed to gain an insight into student’s pre- and post- course understanding of the place of outcome measures in modern mental health services and their reliance on instinct/intuition/experience to assess a patient’s psychopathology. Prior to completion of the course the majority of respondents strongly agreed, agreed or were not sure about this statement, with a much smaller proportion in disagreement. There is a level of concordance between both pre- figures, and one would expect this within a population that had a relatively similar number of professionals who qualified either before 1990, 36% or after 1990, 41%. At the end of the course 80% of the population disagreed or strongly disagreed with the question. The increase here could be put down to respondents feeling more

capable i.e. their self-efficacy has improved pertinent to the correct use of scales - or they may have gained a greater insight into the use of standardised measures in health care - but may not actually be using these measures themselves.

Many mental health professionals rely on their intrinsic ability to know

‘what is occurring’ for their patients, this ‘ability’ is not quantifiable, the next two graphs focus on this by comparing the respondents 'intuition' to the use of standardized and validated assessment scales. There is a marked move from data point 1 to data point 2, with over 80% of respondents in disagreement.

Question sixteen. My instinct/intuition/experience is as good at assessing a patient as any outcome measure:

Graph 20 (pre-course completion). Graph 21 (post-course completion).

Questions seventeen 'I genuinely believe talking therapies will help patients, and twenty, 'CBT is effective in reducing psychotic symptoms in the majority of patients' are both designed to gain an insight into student’s views concerning the efficacy of providing talking therapies to their patients. Question seventeen attempted to gain insight into the respondents’ views on whether or not talking therapies will help patients and question twenty, was designed to identify views as to whether or not CBT is effective in reducing psychotic symptoms in the majority of patients.

The NSW Government has stated that CBT should be available in all Health Care services (NSW DoH, 2008). The results from these questions came out strongly in favour of the efficacy of CBT and for the provision of CBTp, with a marked swing in the CBTp question to either agreeing or strongly agreeing with the statement, 38% pre- CBT course completion to 91% post- CBT course completion, a marked shift in the initial view of the respondents. This data shows that by attending the CBT course, respondents have changed their opinion of where CBT sits in practice. One could assume that this has occurred because the respondents have been exposed to information and training in an area that they were not sure of at the start of the programme. 89% of the population agreed or strongly agreed with question seventeen, at the start of training and 99% agreed or strongly agreed at the end of training, virtually all of the population trained. A return of nearly 100% was never envisioned at the start of the training programme development, but again if this impacts on the development and delivery of patient care over time then the course has been successful. See Appendix 7 for the graphs pertinent to these questions.

Theme - an active therapeutic stance, CTS-R Item 3 - collaboration with the patient:

Questions two 'Patients should be allowed to refuse therapy' and three 'It is part of my role to persuade patients to accept therapy' targeted the student’s views as to patient’s choice in either receiving or not receiving therapy and whether or not part of their role as a health professional was to persuade the patient to accept therapy. The pre- course questions showed that the majority of respondents agreed that this was an important element of their role. This did not alter greatly one way or the other at the post- course questionnaire stage. When one initially introduces CBT to patients, reliance is placed on being able to

‘socialize’ the patient to the model and thus 'grab' their interest and willingness to participate in the therapy. This in itself is not 'persuading' the patient as such, more offering an insight to the processes inherent within CBT, from an educational or psycho-educational perspective (Hawton et al, 1989). Please see Appendix 7 for the graphs pertinent to these questions.

Question six 'If a patient doesn't want CBT there is nothing I can do to persuade them' targeted the respondents' views on their ability to therapeutically ‘convince’ a patient into therapy, pre- and post- course. This question also sits in the theme of active therapeutic stance and collaboration with the patient. Staff delivering CBT as part of the therapy model will use a Socratic psycho-educational approach (Hawton et al, 1989), this is designed to

‘persuade’ the patient to accept therapy by leading them to the personal realization that there are advantages to accepting a course of CBT. Thus I tried to identify students pre- and post course perception of their abilities to ‘persuade’ a

patient to accept CBT. As with collaboration and socialization above this is a core CBT skill, with the focus on providing enough information for the patient to come to an informed and rational decision as to the applicability of CBT to their mental health needs at that time.

The pre-course questionnaire showed that 78% of the student population disagreed or strongly disagreed that there is nothing they can do to persuade a patient into CBT if they do not want it. Post- course showed 100 % of the student population, disagreeing or strongly disagreeing with this view. The implications for this to clinical practice are that we have a population of health professionals who show that they are able to use specific CBT engagement and socialisation strategies to 'persuade' or in other less emotive and more therapeutic words 'engage' a client with CBT.

Graphs 22 and 23 show the pre- and post- course responses to these questions. None of the students agreed or were not sure on this at data point 2.

Question six. If the patient doesn’t want CBT there is nothing I can do to persuade them:

Graph 22 (pre course completion). Graph 23 (post course completion).

Theme – Medication and CTS-R Item 3 - engagement:

Questions five, 'Telling patients about the possible side effects of

Questions five, 'Telling patients about the possible side effects of