In a new paper, Dr. Nev Jones and a team of researchers investigate the experiences and challenges faced by front-line providers who work with individuals experiencing psychosis. In their examination of clinician perspectives on what constitutes best practices and what gets in the way, the researchers found that clinicians emphasize the importance of the therapeutic relationship and personalization of interventions in providing quality care. Several challenges, including systemic and structural barriers, make the provision of these practices difficult.
“Our goal was to lay some of the initial groundwork for intervention and/or policy changes needed to improve the overall experience of the typically multi-faceted and multicomponent services received by clients with psychosis served within the public mental health system and ultimately their impact,” Jones and colleagues write.
While increasing emphasis has been placed on promoting specific, evidence-based interventions for psychosis, and minimizing barriers to treatment, critics of this “dissemination and implementation” movement have expressed concerns that these interventions are pre-packaged and ill-fitted to practical resources and community needs. Jones and colleagues write that the development of these protocols come out of academic settings with resources that aren’t commonly accessible within the broader community. Additionally, some express concern that access to psychotropic drugs has overshadowed efforts to provide access to therapy.
Jones and her team draw on previous research which found “that providers can harbor significant doubts about the applicability of findings from clinical trials to their clients as well as concerns about the potential misuse of research findings to narrowly dictate rather than inform clinical practice.”
The current study explores this disconnect between research and actual delivery of treatment in community settings. The researchers highlight “the perspectives of front-line community providers regarding best practices, clinical ideals, and barriers to quality improvement for clients with psychosis.”
The hope for this project is to improve the quality of services typically provided to adults with psychosis. By centering the focus outside of academia to instead examine provider experiences within the public mental health system, this research uniquely addresses challenges involved in organizational capacity and critical policy and fiscal restraints.
In this study, there were two primary objectives: to examine providers’ (1) “values and ideal with respect to working with/serving clients experiencing psychosis,” and (2) “current state of services and perceived barriers to improving these services for clients with psychosis.”
Thirty-two clinicians were interviewed through focus groups in addition to two individual interviews (6 men, 28 women). These 34 participants ranged in levels of experience and expertise, and participatory methods were utilized throughout the research process. Jones also engaged in intensive ethnographic observation throughout the community health agency milieu, and this provided context that informs data collection and analysis.
The researchers organized their findings into three overarching categories:
- Service and engagement values (or participants’ clinical ideals)
- Detrimental macrolevel constraints on service quality (structural and political reasons why clinical ideals may go unrealized)
- More proximal clinical challenges tied to the multifaceted, multicomponent
Service engagement values
Clinicians expressed the centrality of the therapeutic relationship as the foundation of quality services. Specific techniques were described as secondary and best used flexibly, with room to tailor and personalize approaches. For example, one participant stated:
“For me, in any clinical work that I do, I take it as an approach of ‘we’re in a relationship together.’ I am a human being in this, you’re a human being in this, together we create something that hopefully changes me, and it also changes you.”
Further, participants emphasized building this relationship by “engaging with the subjective meaning of psychosis” by exploring the client’s experiences of psychosis and perceived connections and convictions. Jones and colleagues write:
“Cutting across these discussions of meaning was a belief that psychotic symptoms must be taken seriously—that is, understood as experiences that should be explored and discussed on the client’s own terms.”
The current state of services—detrimental macrolevel constraints on service quality
The themes identified in this category demonstrated that clinicians’ attempts to provide treatment were challenged by “broader sociopolitical marginalization of serious mental illness, constraints imposed by billing and funding mechanisms, staff preparation, and the mechanization of behavioral health interventions.” These barriers were described as interconnected and synergistic. Staff preparation referred to the difficulty of recruited and retaining trained staff members to work in a marginalized center for less pay than other opportunities might offer.
In a discussion about manualized behavioral interventions, clinicians reflected on the following:
“Clin 1: ‘To be good at [working with voices/psychosis], a certain amount of [struggling together] is necessary.’
Clin 2: ‘It’s a more relational way of working.’
Clin 1: ‘Right.’ [Multiple participants sigh in agreement, shake their heads]
Clin 3: ‘Somewhere along the way that got taken out of the mental health field, and more behavioral approaches where the service user is seeing somebody that delivers an intervention [took over], but really—’
Clin 4: ‘Then you measure it.’ [Multiple members shake their heads, sigh]”
Proximal challenges and constraints
The participating clinicians discussed the extent to which they were aware that their client struggled regarding access to basic needs (housing, food, and transportation), and were often residents within disadvantaged neighborhoods. The challenge of providing therapeutic needs amid clients’ unaddressed basic needs was featured across participants’ stories.
In addition to balancing these needs, clinicians were also faced with the task of balancing their role in the client’s life and negotiating boundaries. Clinicians often found themselves assuming various roles while providing treatment through “clinical interventions, housing support, care coordination, daily living, and self-care with clients experiencing psychosis.” Working across these different interpersonal spheres was described as complicated, particularly within approaches centered around validating clients’ subjective experiences. One clinician shared the following:
“A guy who was a voice hearer, and one of his voices ended up being my voice, was saying things that I wasn’t saying or feeling. I, at the time, just took the approach of being like, ‘I didn’t say that. Here’s what is real about our relationship.’ I do not know, now I’m not sure if that was the best way to do it.”
Implications
Jones and the research team underscore how this work illustrates a need for research focused on strengthening agency and provider capacities to work within systems and the complicated realities of serving individuals with psychosis. This contrasts with exclusively providing specific, decontextualized interventions, such as, “cognitive-behavioral therapy for psychosis group or brief trauma-focused intervention.”
Overall, these findings demonstrate that “providers in the public mental health system typically interact with clients in multiple, multifaceted ways, struggle to meet overwhelming human needs (and degrees of socioeconomic disadvantage) and navigate complex moral and ethical challenges, all under the auspices of a heavily bureaucratized and underresourced service system.”
Rather than continuing the focus on implementation, Jones and team recommend shifting toward adaptation. This applies to both personalizing at the micro-level with the fortified client-therapist relationship, but at the macro-level within complicated agencies and structures.
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C Jones, N., Rosen, C., Helm, S., O’Neill, S., Davidson, L., & Shattell, M. (2018). Psychosis in public mental health: Provider perspectives on clinical relationships and barriers to the improvement of services. The American journal of Orthopsychiatry. (Link)
