Dramatherapy in Early Intervention in Psychosis

Focusing on NICE guidance for improving patient experience of care and AHP into action goals

Addressing health inequalities by enabling patients who cannot talk of their troubles to access treatment. Implementing NICE guidance by working with the patient as an individual, starting with what they can do:  embodiment or projection through objects when words are too difficult. The goal was to engage patients who had a series of inpatient stays and had disengaged from the service. NICE advocate group art therapy for patients who experience more than 1 psychotic episode to enable them to express themselves, engage with others and understand their feelings. This project was initially to test DTys relevance over 3 years. Early success led to extra funding to both create a manual and build research capacity by collecting more data in Leeds, and applying the model in York EIP for 5 years (2015-20)

Support healthier communities, by supporting isolated patients into the EIP community they benefit from healthy living and social initiatives. Team work to improve communication between disengaged patients and staff. DTy was to enable staff to get to know patients not accessing the service, or where assessment had been compromised because of their inability to express themselves.  We aimed to improve social function so patients could progress to other EIP groups and CBT. Disengaged clients can be costly; missing appointments and at higher risk of being sectioned against their will. Their risky behaviour means they can be a worry for staff and a drain on resources. Re-engaging them supports efficient working.

To enable patients to get the right treatment even when they are unable to answer standard questions. NICE guidance highlights the value of good assessment, in phase 2 we extended the project to all uncommunicative clients.  Early sessions were designed for patients to create their own recovery targets. The Service goal was for patients to improve awareness of their mental health; to recognise triggers. DT aimed to nurture self-care skills whilst patients controlled the content and progress of treatment.

To address the lack of evidence by recording change in social function and self-esteem before and after treatment, and collect patient feedback to understand what activities worked. Learn from patients about obstacles to engagement and share findings widely.

In 2011 the service wanted to address health inequalities by testing DT. If found useful to patients, they would attempt a feasibility study into the possibility of a small randomized controlled trial (RCT).

NHS funding rightly follows evidence. In 2016 large funding was exclusively directed at Family Interventions and Cognitive Behavioural Therapy (CBT) due to their efficacy in research trials despite uncertainty about the effects (Jauhar et al., 2014). However CBT is not always appropriate.  One trial reported (Startup, Jackson, and Bendix, ), 60% of CBT patients achieved statistically reliable, clinically significant change, meaning 40% did not. We needed to understand what could be offered to these patients for whom talking treatments do not work.

NICE guidelines recommend arts therapies for psychosis; “arts therapies are the only interventions demonstrated to have medium to large effects on negative symptoms in people with schizophrenia.” (NICE, 2014, p. 220). There is growing neuroscientific evidence in support of bodywork in the treatment of the types of trauma often seen in those experiencing psychosis (Van Der Kolk 2014). However, arts therapies are rarely employed in EIP.

At the start of this project there were no other DTs employed within (EIP) services in the UK this maybe because DTy has not been tested. We suspect this is because DTs work with people at the margins where it is difficult to research. An examination of Mental Health RCTs underway in 2015 indicated that none included complex presentations/diagnostic uncertainty. This is a population that DTs are specifically employed to work with. Since the Cochrane review was inconclusive about DTy, DT posts have been cut. This is a problem given early findings (phase 1) indicated 30% of patients that were disengaged  did engage in DT.

With positive early results local NHS Trust LYPFT funded analysis of patient feedback to hone the intervention for research. Patients were unanimous that once they tried DT they would not tolerate a waiting list control group. Power is a vital subtext in interactions with a population that may have had inpatient stays and drug regimes imposed on them against their will so we were presented with a problem. We cannot ethically test our findings against a research control group but struggle to publish data without it. 

A DT was hired 1 day a week to develop a model with a view to a feasibility study for an RCT.

Referrals were initially a problem as staff didn’t know what DTy was and patients were scared of the idea of group DTy. We ran group taster sessions for staff. We called it “wordless therapy”, created a leaflet including the reflections of early treatment graduates and distributed it through care coordinators and inpatient areas. Patients self-referred by handing leaflets to staff.

6 months was spent:

• researching best practice based evidence globally
• considering appropriate research methodology to measure change pre and post treatment
• introducing DTy to staff and patients before delivering 2 groups a year initially for 3 years  (phase 2 is until 2020)

This resulted in a new client centered approach with 6 pre-group sessions.

1 – A taster assessment session with patient in control of content. Freedom to also control the length, frequency of sessions and attendance of supportive family/friends/staff improved patient engagement. 2 more sessions enabled patients to understand DTy

4 Review. Patient and DT reviewed the options, some progressed directly to mainstream groups and CBT.

5-6 If ready for a DTy group patients used these sessions as rehearsals to prepare for the first group session. This reduced anxiety as patients knew what to expect.  Engaged patients who were not yet ready for group had individual DT until the next group began.

Groups involved 12 x 90 minute group sessions in a community space with 2 staff participating as equals.1 Individual session with DT completed treatment.

We chose easy to use pre and post measures familiar to the staff who needed to complete them with the client directly before starting and upon ending DT. Staff completed a satisfaction and change interview with patients.

Patients were free to repeat the group/move onto other groups

A big challenge was to do research. Clients withheld consent. Collecting data relied on busy staff. Patients did not want to admit DTy was ending and avoided the closing forms. LYPFT funding meant we could conduct patient feedback sessions, we realized that an RCT was too ambitious. In phase 2 of the project we factored in more staff research time.

Phase 2 2015-2020 includes developing DTy in York EIP and more therapy hours in Leeds to collect more data, understand our findings and share results as widely as possible.

Equality of service

Phase 2 data shows DT engages 15% of all EIP patients under 40 years old.  A third of them progress to main stream services after less than 6 sessions. Of those remaining 40% use group DT. With (60%) needing more individual work.

Phase 1 results show 30% of those referred made significant change which is impressive for a cohort defined by their resistance to services. There were less hospital admissions with 1 patient self-admitting instead of self-harming.  Only 25/40 patients agreed to have their data recorded. At the end of treatment there was a mean improvement of 3.5 points on the 30-point self-esteem scale (Rosenberg) and 13.4 points on the 100 point (SOFA) scale, both are statistically significant. This included 44% Black/ethnic minority patients.18% of patients had a known disability.

DT service quality improved due to patient feedback. Only 30% chose to proceed after a taster session in Year 1 but in phase 2 88% of patients engage. Group attendance improved from 35% in group 1 to 97% by group 3

Working Together with Team:

Every patient set personal goals in their first DT sessions. (Phase 1) 6 month follow up indicates the wider team supported them to attain these after DTy ended. 18 patients were successfully tracked. 3 were living independently.  13 had improved social contact 14 were in or looking for structured education/work. 17 recorded improved mental health; the service goal for the project.   

Staff learn about DT and their clients by engaging in sessions as equals allowing distant clients to bond with them through shared experience. Witnessing DT assessments is time saving “I learnt more today than from 10 hours of contact time” Allie Lewis Care Coordinator

Patients’ new found self-expression is cost saving as attendance across the service gets easier. CQC inspections included many DT patients who had become vocal as a result of DT (see last section for quotes from CQC). 

“It has helped me to get in contact with my emotions – for example anger. It has helped me be less closed and more open, more welcoming. I think it helps in everyday situations such as trying to get along with people. I also think it has helped me feel more enthusiastic and confident” MW patient.

After a first episode patients can struggle to understand the body language of others and “over think”, so they isolate themselves. CBT as first treatment can compound feelings of failure for some.

NICE guidelines suggest DTy only after other treatments have not worked but for 15% of population we found DTy ensured quality assessment with uncommunicative patients, resulting in better care plans and good engagement with EIP services afterwards, often leading to CBT and Family interventions as recommended by NICE.

Dramatherapy :

• Supports the prevention of hospital readmissions that can reduce patient chances of full recovery
• Engages risky clients so they take up less staff time resulting in cost savings over the 3 years of treatment and are more likely to engage in standard rehabilitation with better long term outcomes
• Addresses this population’s shared struggle to say no, which can waste significant resources because of misleading communication.

To tolerate attempting recovery there are core conditions:

Freedom: Patients never have to do anything, they can engage by watching, or copying others without having to contribute

Perspective; the room is used to provide appropriate distance at all times, boundaries to contain either positive or frightening material are important

Patient is expert (NO is celebrated, therapist constantly checking it’s safe to continue)

Patient controls the distance from issues, space, time, room layout 

Work is future focused, ambitions reinforced as far ahead whilst therapist attempts to attune to patient and embody/reflect on what is seen

Patient doesn’t have to share the meaning of created objects. They are free to be open or closed with others

Using creative DT processes to articulate the problem, patient retains control of what is shared and what is contained

Six pre-group assessment sessions are essential.

DTy works best when connected to social recovery work across the service, EIP staff support this by helping patients to attend and take part in groups

Staff can get stuck with “resistant” patients, DTy can provide new information to get things moving and provide new ideas to support the whole team effectively.

A research trial is not viable without more DT capacity across NHS locations. Research must accommodate patient resistance to waiting list control groups.