Hello, good morning, everybody, or good afternoon if you're on the East Coast. I want to welcome you to today's webinar on Psychosocial Interventions and Coordinated Specialty Care, CBTP, and IRT. I am Judith Doberman, the Program Manager for PetNet at Stanford University's School of Medicine. Today's webinar is brought to you as a partnership between PetNet, SMI Advisor, SAMHSA-funded initiative implemented by the American Psychiatric Association. We will be offering CEUs for physicians and psychologists for the live presentation today, and we will share the information with you on how to claim CEU credits at the end of the webinar. So, a couple of logistics items. Please post your questions to the chat box, and you'll find the link to the chat box in your Zoom control panel, which could either be the top or the bottom of your screen. And also, please, when posting your questions to everyone, please make sure that you select everyone in the drop-down menu at the bottom of the chat box. You'll see either you can select everyone or you can select panelists. If you select panelists, it will just go to us, which is fine, but if you want to share your questions with everybody, make sure that you select everyone. So, a little bit of information about today's presenters. Dr. Kate Hardy is a clinical-licensed psychologist who has specialized in working with individuals with psychosis for over 15 years in both research and clinical settings. Dr. Hardy received her doctorate in clinical psychology from the University of Liverpool in the UK. Dr. Hardy has significant experience in providing CBT-P to individuals with early psychosis and those at risk of developing psychosis in both individual and group settings, and integration of its clinical intervention to broader systems and staff teams, and has led multiple trainings and workshops in CBT-P to a wide variety of audiences, including community clinicians, psychiatrists, and families, and provides ongoing supervision and consultation in this approach. We also have Dr. Piper Meyer-Calos, who holds a doctorate degree in clinical rehabilitation psychology from Purdue University. She has specialized in psychiatric rehabilitation and treatment for first-episode psychosis with interests in – let me advance the slides here – with interests in recovery, positive psychology, and psychosocial treatment for people with severe mental illness. Dr. Meyer-Calos's current research includes an evaluation of four first-episode psychosis programs in Minnesota and the National Early Psychosis Intervention Network, or EPINET. So, let me turn it over to Dr. Meyer-Calos. Thank you. I appreciate that, Judith. So, just before we get started, these are our three areas that we're hoping that people will be able to get out of the webinar today. So, we're hoping to talk a little bit more about CBT-P and how it applies to early psychosis, to explain IRT and its implementation in coordinated specialty care, and to compare the two models and opportunities for integration. Next slide. I almost tried to advance it myself, so I have to remember to say that. Here's how we're going to roll it out today. Kate and I are going to share the stage a little bit, and we're really excited to actually be talking to you about this today. The two of us, along with some other colleagues of ours, have been talking about this integration or what the two interventions, how they can work together and complement each other for a while. And we get really excited because we see all of the wonderful possibilities for this, and so we're excited to kind of share what we've been talking about for a while. I'm going to start out and talk a little bit about psychotherapy in early psychosis, giving you an introduction to IRT, and then I'm going to turn it over to Kate, who will give you an introduction to CBT-P, and we'll talk a little bit about integrating IRT and CBT-P. Next slide. So just a little bit of a background here, you know, many of you may know this, that the U.S. started late in getting into the game of what should early intervention models look like in the U.S., and part of that happened with the rollout of the RAISE model, so that's recovery after initial schizophrenia episode, where there were a couple of national studies national studies that happened, and that's where we actually got where IRT, or individual resiliency training, was developed. But before that happened, traditionally, most of the individual therapy interventions included either CBT or a CBT for psychosis intervention, and that was mostly the standard approaches that you would see in early intervention studies outside of the U.S. When RAISE came along, specifically the NAVIGATE intervention, so that was the larger randomized controlled trial, it included these four listed interventions there, which was family education, supported employment and education, medication management, and individual resiliency training, or IRT, as we'll refer to it. So IRT was the individual therapy intervention, and I'll tell you a little bit more and kind of break that down, but that was the piece that we included with NAVIGATE. Next slide. This was all in the service of what is now called coordinated specialty care. When we were doing RAISE, that was before they gave it this name, but essentially after the RAISE project, what they did when we came back and compared the models that had been developed within this multi-payer health system, we realized that there were several similarities across the models, and this is where the coordinated specialty care model was born. So you'll see here what it shows you is that the person is in the middle of this, and the care surrounds them in all of these different areas, and it's in this framework of shared decision making. So this idea that we are including the person and they're driving the treatment and what they need at certain times may differ. So you've got all of those elements that I talked about before. You have medications, you have supported employment and education, you have family education and support. In addition, case management is another element. We combine that with IRT, and then you also have cognitive behavior therapy. Next slide. So I'll just say that the coordinated specialty care model is how early interventions were rolled out across the U.S. That's the model that we have asked people to kind of pay attention to and adhere to. Within that is, talks about kind of a CBT or supportive therapy intervention, and that's where IRT and CBT for psychosis come in, because those are the two predominant models that you'll see that are rolled out across the U.S. And we wanted to start off and talk a little bit about how are they similar? What's similar about them? Because I think it kind of feeds into and goes into the importance of how they can be integrated. So they are both actually evidence-based approaches. CBT for psychosis, as Kate will talk about, has a long history of an evidence base. And IRT is a newer evidence base, but it was a really large randomized controlled trial that at the end showed improvements in quality of life, in symptom reduction, in reduction in depressive symptoms, so in a number of things. And so they are both actually evidence-based. They are both based on this collaborative approach. It includes the person. The person's goals are really what's important and what are driving things. So they're both based in this kind of collaboration. They both use psychoeducation as a way to normalize what's happening, the person's experience, and to challenge stigma. So that's a key feature that you'll see in both of them. Goals and problems are prioritized. So again, it's the person that makes the priorities or sets where they want to focus on in treatment, and that it's all done this idea of trying to support the person to improve their functioning and to increase their resiliency. And then last, but certainly not least, that both of them have a lot of flexibility that are built into them so that they can be adapted based on the person's cultural background, their needs, their traditions. What is important to them can be integrated into both of these interventions to really make it look like what's going to work the best for that person. Next slide. So in addition to kind of the general kinds of things about the way it's set up, there's some structural similarities between IRT and CBT for psychosis. Both can be provided in outpatient settings, and both happen within a team-based approach. So IRT was specifically built into the NAVIGATE model. It is one of the four pillars, the legs of the interventions. And CBT for psychosis works also within kind of a team-based approach. They also both require a fair amount of clinical competence. Some of that we assume people have before they start training, and some of it they gain while they develop the training. So some general areas that we think are really important that people come to both of these interventions with are a recovery orientation, collaboration both with the individual and with people on the team, this idea of really engaging the person in shared decision-making, and using respectful communication. And then last on this list is that both of them, the models where people learn these intervention are heavily based in the need for training and consultation. So with IRT, although the manual is available online, and I'll talk about that, we think that people are best served when they get training, and then after training receive ongoing consultation for about a year, that that's where the implementation really becomes the best. And CBT for psychosis is the same way, that there are several different flavors you might think of of CBT for psychosis, but people can tend to roll this out best when they receive some training and some ongoing consultation to help integrate it into their practice. Next slide. So what's interesting, though, is as we rolled out early intervention in the U.S., and as some of these different models, and CBT for psychosis and IRT being the two largest ones rolled out, we started to get more of these questions about, did it have to be an either or, or could it be an and? And the more that we kind of started talking about this with some colleagues and thinking about this, we noticed that there were some common challenges that we both were facing in these early intervention models, and these won't be a surprise to you, right? We often will see high rates of disengagement. You know, this is a younger population. This is a population that does not want to be sick. They often will find lots of reasons for disengagement, and if there might be tools that are built within each of these modules or models to help with that, that might be really helpful and important. We also know that, particularly in early psychosis, many of the individuals that we work with struggle with low insight, and that factors into that engagement factor or non-engagement. It factors in how they see treatment, how they engage with treatment, how often they come to appointments. It can affect a lot of areas, and again, both of these interventions actually offer tools for that. The third bullet there, again, no surprise to anyone, is that many of the individuals just suffer with difficulties with medication adherence. The medications sometimes have these side effects. They sometimes don't make them feel like themselves. What do we do about that? How do we work with people on that? How do we work as a team around that? Both of these models offer some different strategies for this that actually can be combined and work together very well. There are two questions that we think about, and we started talking about how to apply the best intervention and treatment, and how to integrate using both interventions and treatment. So thinking about when to roll out each of these interventions, are there situations that come up that might suggest one intervention might be more applicable at a time, and another intervention might work better at a different time? If a clinician is using both interventions, what does that integration look like? Because these can be large interventions, particularly IRT is a large intervention, and it can be daunting to think about rolling out two evidence-based practices at the same time. So that kind of gives you a stance of where we're starting from. I'm going to now provide a little bit of an overview so you know a little bit about what IRT is, and then I'll turn it over to Kate, and Kate will wrap it up. Next slide. All right, so I'm going to talk about Individual Resilience Training, or IRT. So next slide. Okay, so when we think about IRT, it's built on this foundation of strengths and resiliency. We're coming from this place that our main goal is to help people get back to doing what's important to them, and that's often the way that I describe it when I'm describing it to an individual I'm working with, is that we want to help you get back to doing what's important to you, and our focus in doing that is going to be to help you build your strengths and build more opportunities for resiliency. Now, the way that we do that is we help people learn information, skills, and strategies to help them better manage their illness and get back on track. That's what the modules in IRT are for, and that's what I'll show you in a minute on the modules, and the information is organized by these topics that are organized into a module, so it can be rolled out and built within there is a wealth of information, so some educational information, some opportunities to elicit those personal experiences, and so a lot of discussion, as well as a fair amount of skills so that people can learn skills to help them in a certain topic, but no matter what happens about IRT, and I'll show you how large it is here in a minute, we always believe that it's tailored to the individual person, that whatever their choice is around what's important to them, what their goal is, that's going to be the priority, and in fact, what we'll say oftentimes in IRT is that we come back to that person's goals, we review and talk about that person's goals every time we meet with them, and so what we cover and how we individualize the material depends on their person's goals, and then we can adjust it in different ways to meet their needs, sometimes when they're experiencing more symptoms, sometimes when they have new symptoms come up, sometimes their family situations might change, these are all things that we can adjust to and build in in IRT. Next slide. So this is what we call the standard modules of IRT, and it's broken down into these what we call these standard modules and the individualized modules. The standard modules are meant that anybody who comes in for treatment in an early intervention program could benefit from these modules. These are what I think of as the more foundational topics that at a bare minimum a program should be addressing these areas. They are applicable across most people, and they typically, most people come in need some of this as just a basic foundation, so what you'll see in here is we start out with a basic orientation and we go right into that individualization portion of it. We go right into this idea of setting goals and understanding what's important to that person and what is getting back on track look like for them and how can we help them do that. We come in after that and we provide a foundation of education, so we put forth a basic foundation of symptoms, diagnosis, stress vulnerability model, medications, stress, that's all built into that fairly large module. We also include in this standard package some information about healthy lifestyles as we really want to address those areas as early as possible. We know that long term people with a diagnosis of schizophrenia end up with lots of health problems and so this is our opportunity to start that education early. Then we move into developing a wellness plan, so here's where we're teaching relapse prevention planning. This is in fact coordinated along with the education with our family program, so what you'll notice if you align both of those manuals together, it's almost word for word the same information. It's very, very transparent. We did it very intentionally, so those two things are actually coordinated together. Module six is probably one of the most unique modules that we have and this is based on a PTSD formulation where we give people the experience of processing what happened to them when they experienced psychosis for the first time and it gives tools in there to help somebody who is experiencing a PTSD reaction in response to the experience of psychosis for the first time. Then the last two are really around getting the person building up those resiliency skills and helping them even more towards their goals. These are the standard package that again we assume that most people that are coming in are going to be able to benefit from that. Excuse me. I thought I was going to sneeze. I guess not. Okay, next slide. The second batch of modules is what we call individualized modules. These are not everybody who's going to come in is going to need or want to do these, so it's just not something that everybody's going to need. We see this as building on to that basics of what's in the standard modules. What we have in here are two modules that are focused on coping symptoms. One is cognitive coping strategies based in a CBT perspective and the coping with symptoms is more behavioral-based coping strategies. Then the other two topics there, substance use and having fun, developing relationships. Again, these are common topics that we know that come up, common issues, common things that people want to talk about in treatment, but they're not always not everybody's going to have a need to go through them. That's the way that IRT is organized. It's a large intervention. You can see from these two the way that we've broken up the modules that it is a lot of educational information and a lot of skills that are built in a manualized way in this intervention. If you go to the next slide, I'm going to talk a little bit about the way the manual is set up because I think that this is a really important thing. The manuals are available for download for free. This was part of our agreement when we developed these, so anybody can download them. In fact, I'll even note that last April we finished an update on all of the Navigate manuals, including the IRT manual. That updated version is also on the NavigateConsultants.org website. You can see here, this is how we talk about organizing the manual to make it easier to really understand and follow. We talk about is breaking down into one binder with the standard and one binder with the individualized. Within each module, it's broken down into what we call clinical guidelines and participant handouts. The guidelines you can think of are what we put in there for you, the practitioner. The participant handouts are what you use when you're in session with an actual individual. The difference between the two is the clinical guidelines pages have borders around them and the participant handouts have no borders. One of the easiest ways I can tell you to break this up is that if you're going in and you're looking for a handout, you're looking for those pages that have no border on them. You can tell what we did in here is we built in those clinical guidelines to really help you, the practitioners, who may not have training yet or may have had training but have more questions that you want to go back. This will give you step-by-step guidance to roll out that particular module or that particular topic. There's guidelines for each of the modules that I showed you earlier from the standard and from the individualized. IRT integrates several treatment approaches. That's the thing that's unique about it is that we've really tried to put together the best of the best. It includes some of the cutting leading edge of what I think of including in treatment for people with schizophrenia around positive psychology, this idea about activities to help people increase positive emotions, to some of our standards around illness management and recovery and motivational interviewing. It also includes, which is why it makes it so easy to integrate IRT with CBT for psychosis, it includes CBT. It includes a CBT framework, the way that we structure sessions in IRT. You can see there are two big modules that focus on teaching different kinds of CBT coping skills. They are all aimed at improving and increasing resiliency, sustaining wellness, and using that relapse prevention to avoid going back into that hospital or experiencing those kinds of disruptions. Next slide. When clinicians roll out the IRT modules, they're using motivational, educational, and cognitive behavioral strategies in every session that they do. We have built those in. You'll find those in those clinical guidelines I was talking about. In addition, these are some of the things that don't always come through in the manual. In IRT, we are always teaching these skills, teaching this information in the service of the person's goals. We're providing education on all of these different topics, but it's always in the service of helping the person identify their goals or reduce some distress. The other thing that you'll see that's really woven throughout the IRT modules is this idea of developing a resiliency narrative so that we can provide this opportunity for the person to build that narrative. And it starts from that second module, in fact, when we do strengths, and it culminates by processing the episode. Next slide. So the other thing that I think is kind of unique about IRT is that it focuses on many areas that are less illness-related, more about getting back on track and what the young person might find important to them. Many young people really enjoy talking about and feel good talking about health and wellness and nutrition, exercise, and sleep. There's a whole module on that. Many people, their peer relationships are really important to them, as they should be. And there's a whole module that's dedicated to developing skills and providing opportunities to have fun and developing relationships with other people. We also have a module, and in fact, this is one that got redone in that new version around substance use problems that we've really tried to re-envision a way to approach the high rates of cannabis use. And then lastly, as I mentioned, there's a fair amount of positive psychology that's been infused in here. To really, in a very concrete way, help people build that resiliency narrative. Next slide. So the last thing I wanna mention before I turn it over to Kate is that IRT was developed to be very individualized. As a result, it is very easy to adapt IRT based on that person's background. So you can individualize that approach. You can actually include family members as we know that the family approach and the family education component is similar education, but you can really individualize it based on that background. And you learn about that. There are opportunities to learn more about that background in the satisfaction with areas of my life, which is where we use that as a tool to help us do goal setting. Goals are another area where they can be very individualized to address some of those cultural differences. Again, we can include family members, we can include community members, depending on what the person really wants to do and what's important to them. And the last thing I'll mention is that we have had a fair amount of experience implementing IRT in different countries. It's listed here as in Israel and China. We've also have an implementation in Canada right now as well, but the ones in Israel and China have really been helpful to understand the importance in some of the bigger cultural adaptations that we've seen. So I believe next slide should be turning it over to Kate. Absolutely, your turn, Kate, I'm gonna turn it over to you. Thank you, Piper. And thanks to everyone who's been submitting questions so far, please continue to do so. And we'll get to those in the Q&A. So I'm gonna talk a little bit now about cognitive behavioral therapy psychosis. And Judith, if you wouldn't mind taking us into the next slide. Thank you. So just to make sure that we're all on the same page with what the CBT thing is. This is a really sort of common depiction of how we think about a CBT model or kind of cognitive model. And essentially it's how our thoughts and our behaviors impact our emotions. It's commonly said that emotions do not easily change if they responded well to things like saying cheer up or don't worry about it. If that actually worked, then none of us would actually have jobs. And so we know we have to find other routes in to working with distressing emotions. And that in CBT is through working with the cognition. So how we think affects how we feel and how we act and through exploring behaviors or actions because we know what we do also affects how we feel. Obviously it's all connected. CBT hugely applied across a whole wide range of mental health problems in weight management, sports psychology, organizational psychology and of course applied to psychosis as well. Next slide, please. Thank you. So what is CBT for psychosis? How does this work? Well, the focus is really on trying to reduce the distress caused by positive symptoms such as hallucinations and unusual thoughts and increasing functioning by addressing those experiences and also negative symptoms. And it's important to note that we are focusing on reducing distress and not on reducing the symptoms themselves. And we can do this in two ways as is common to CBT. The first is by looking at a person's thoughts and it's the interpretation of the event that causes the distress rather than the event itself. True of all CBT and certainly true as you think about it for psychosis. So this might be an example of somebody coming to you telling you that they are really scared to leave their house because they have seen five blue cars past their window this morning and five is obviously the color of the mafia and that must mean that they're in danger from the mafia for example. And so it's not the five blue cars that are causing that distress but it's how that individual is interpreting that situation. And so here we might help the individual check the accuracy of that interpretation. Because it's CBT, we don't just want to work at that cognitive level but we can also work at the behavioral level as well which is really important because not everybody is necessarily going to find it easy to access their thoughts in a situation. True for psychosis, true for other mental health problems, true for people who aren't seeking services at all, just isn't always easy to sort of access our thoughts. So we have this other way in which is about addressing behaviors. And here we might want to look at how apparent behavior is maintaining the problem and then check the helpfulness of that current behavior. An example of this might be somebody who is spending all their time in their room talking to their voices at the detriment of their activities of daily living for example. And so without even having to look at the thoughts here we might want to look at the behavior, see if the behavior is helping the person move towards their goals or not. Maybe negotiate a period of time away from talking to the voices to go do the laundry. So just directly working with the behavior there. Next slide please. It seems, I think certainly here in the U.S. as though CBT-P is some sort of new kid on the block. But actually it's been around for quite a long time and was first described back in the 1950s by Beck, widely regarded as sort of the grandfather of cognitive therapy. And one of his first case reports was on cognitive therapy for an individual diagnosed with paranoid schizophrenia. But it kind of sort of disappeared from view at that point as more attention was placed on CBT or cognitive therapy than for depression and anxiety. And I think there's a number of reasons why that was the case. I think first of all, certainly here in the U.S. there's this very prominent biological and medical model for understanding psychosis. And so if we reduce everything down to being purely about neurotransmitters, it removes the opportunity for us to think about how talking therapies might be helpful. So certainly taking those at the forefront of explanations for how people experience psychosis pushed the opportunity for psychosocial interventions to feel less relevant. There were studies in the 80s that reported that talking therapies were at best ineffective and at worst actually damaging to individuals with psychosis. And just this long held assumption that somehow psychosis lies outside of the realm of normal psychological functioning, whatever that might be. And we can trace that all the way back to how psychotic symptoms are first described and classified by the kind of very early psychiatrists thinking about sort of dementia precox and the evolution of this term. So all of this kind of really led to this sort of othering, this therapeutic nihilism that I've heard it termed. Until in the sort of 80s and 90s, it started to be more of an interest in how could we take existing models like CBT and start to apply it to schizophrenia and to psychosis and really the development then of new models, new ways of thinking about this. And within this, and I think Piper sort of said this a little bit earlier, this sort of umbrella term of CBTP with different approaches. And I think some of you asking the question at the Q&A rather about recovery-oriented cognitive therapy, and that's certainly falling under this umbrella of CBTP. Next slide, please. Piper's also mentioned a lot about the evidence-based and of course that's very important when we're considering training clinicians and offering interventions to clients. We want to know that they're effective. And because CBTP has been around now for a couple of decades, or at least around and well-researched, we know that there's a good evidence-based for this approach. So we know it's highly acceptable to consumers, that meta-analyses have demonstrated reductions in positive and negative in general symptoms. Although remember, our target of the CBTP is not actually symptom reduction, it's distress. And more recently, clinical trials have moved away from sort of being symptom-focused and looking more now at sort of functional outcomes and recovery-based outcomes, outcomes that are being reported as far more meaningful to individuals. And these studies have a lot more service user researcher involvement, and they're really highlighting that this is where our focus needs to be in terms of outcomes. Sorry, it's got noisy outside. I hope you can still hear me. We are talking here about CBT for early psychosis, but we can also think about how this can be applied to the clinical high-risk population. And again, meta-analyses have demonstrated that when applied to those individuals who are experiencing attenuated psychotic symptoms, so not yet fully in the full psychosis bracket, but in that pre-psychosis or the clinical high-risk bracket, that we can see reductions in transitions to psychosis at 12-month follow-up. And in fact, CBTP is one of the primary interventions recommended to that population, rather than, for example, antipsychotic treatment, which isn't recommended for that population, because they have not yet fully developed psychosis. And there's this nice meta-analysis conducted last year by Turner et al, that sort of concluded that there's now sufficient evidence for CBTP to be effective for hallucinations and delusions. And they were really arguing that we need to be focusing now in different areas, such as functioning and recovery outcomes. Next slide, please. Of course, it's not without its critics, and I wouldn't be a good CBT therapist if I wasn't giving sort of a balanced view of this. So I also wanted to just highlight a couple of papers from Sameer Jahar and Keith Laws, who have certainly taken a stance, particularly in the light of wide-scale CBTP rollout in the UK, or particularly in England, and a lot of investment in training. And, you know, they're really trying to look at very stringent masking for meta-analyses, looking at outcomes of functioning, distress, and quality of life. Next slide, please. But we want to be thinking about those papers in this context, which is that CBTP has never been presented and shouldn't be presented as a quasi-neuroleptic. This is meant to be something that is offered usually, typically, as part of a team approach. And as I've mentioned, this kind of continued focus on symptom reduction is sort of unhelpful when we're reporting these outcomes, when our focus really is on distress, and now more commonly on functioning and recovery outcomes. However, there's no good measures of reduction in subjective distress. So we need to get better at measuring this and reporting distress. As we've mentioned a couple of times, CBTP is this blanket term, and there are these different models of CBTP that exist now. You know, I think you could get, I know you can get, because I've done this, multiple CBTP experts in the same room and ask them to define what they do and look at the commonalities and differences of what they do. And this can get to be a very, very deep and involved conversation. So just labeling these models as a single thing can be quite unhelpful. So we need to get better at categorizing and refining how we categorize these different approaches. And often in clinical trials, CBTP is being measured as a single intervention when certainly here, as we're talking about it within coordinated specialty care, more typically it's being utilized as a team approach. So we need to be thinking about how is CBTP an added benefit to these teams, rather than trying to measure it as something different or separate. But I can certainly say there's a lot of momentum in the field to continue to address these challenges. I knew I tried to advance the slides on my own. Judith, could you do it for me? Thank you. Piper did it too. It will then eventually, Piper. Pigeons would do it faster. We're talking about CBTP in the context of coordinated specialty care. And so I'd like to put this slide up as well, just to really speak to how the principles of CBTP very much align with what we see to be the global consensus of what the principles of early intervention should be. And this comes from an old yet seminal paper from the World Health Organization on these early intervention principles. So you can see, we want to be really prioritizing, actively partnering with young people, providing interventions with demonstrated efficacy, challenging stigmatizing and discriminatory attitudes. And we're seeing CBTP offering this through being evidence-based, making sure that our generated problem list is really client-driven, and it's a highly collaborative approach as we've seen with IRT as well. And then in the work that we do through CBTP, we're developing the shared understanding of these experiences through what's called a formulation that I'll talk about in a little bit. Now, you can see the other elements there as well. Next slide, please, Judah. So just to give you a little bit of an insight into what this looks like, obviously I don't have time, neither did Piper, to give the full overview of what CBTP really needs to encompass for us to be able to do this effectively, but sort of breaking it down generally into these five steps. One of the key elements of this approach is this initial engagement and befriending period, really working on the premise that unless you have a strong therapeutic rapport, a therapeutic alliance with the individual, we are not going to get very far. And so this could be the first five minutes of the first session, this could be the first five months of working with the individual, and you're really building rapport and developing shared goals during this time. So this is almost like a pre-CBTP period, but it seemed to be integral to the work that we do. Once we have a firm setting, or it feels like we have a firm relationship from which to start to work, we then move into being more curious about the experiences. And within CBTP, this kind of period of time or this experience is known as sort of sitting on the collaborative fence. And it's this opportunity to very curiously and without judgment, explore the experiences that the individual is reporting and invite them to sit in that same place of curiosity with you to be really interested in these experiences and possibly other explanations for them. And the reason why we call it sort of sitting on the collaborative fence is because it might require a shift for the clinician to move onto that fence and sort of balance that, moving away from the assumptions they hold about the client's experience. And in doing that, we're inviting the client similarly, maybe drop their assumptions just for a little bit to come and sit on that fence with us and be really curious about it. We can both return to our own sides of the fence at the end of that experience, but just in that moment, let's kind of drop all our assumptions and be really interested in this experience. Very open exploration of symptoms, experiences, and highly normalizing approach as well, where we're trying to decatastrophize these experiences and see them through maybe a more normalizing, within a model of continuum of psychosis that these experiences individuals have are more common than many people realize and understanding in that context. Once we've developed this, once we've gained this information through a very curious exploration, we can then move into formulation development. And that's essentially helping an individual make links between their early experiences, what we call core schema or core beliefs, their unhelpful thinking patterns, and then what behaviors or responses potentially maintain the distress or the current experience. And that's often, but not always, I did it again. Judith, would you mind moving forward? Thank you. As often, but not always, visually represented. Formulation is really sort of key to the CBTP approach, and it's an essential component. This is a Delphi study that was recently published as an expert consensus of what CBTP is. And this formulation was really kind of highlighted as absolutely critical with a focus on understanding of risk within that formulation and an understanding of how behaviors potentially maintain problems. Formulation allows for co-creation and meaning-making of experiences as well. So this is particularly helpful where an individual is potentially rejecting maybe a medical or a diagnostic understanding of their experiences, but are curious to understand other pathways into what they're experiencing right now. Again, we're holding different models, but then making something that's potentially very meaningful to the individual that helps them to understand how these experiences may have come about. Developed collaboratively with the client and then helps to guide intervention. So we could spend time developing this beautiful formulation with arrows and colors and pictures and everything, but unless it then gives us a roadmap of where to work and what intervention to do, then it is going to be useless to us. So it should really then tell us what level do we now need to intervene. And then it ensures that our interventions are grounded in elements that are very meaningful to the client. Like I've said, it allows for exploration of alternative and acceptable interpretation of these experiences and can very much be focused in the here and now, but draw upon past experiences to explain development and maintenance of current difficulties. Next slide, please. And this is just a kind of a very quick formulation as a sort of demonstration, which probably isn't that helpful without a whole load of context, but what I just want to show here, very much based on Anthony Morrison's interpretation of intrusions model that was developed back in 2001. But here we have the event of an individual hearing a voice. Their interpretation or how they make sense of that is that the voices are demons and they've got no control over this. If we go down to the bottom left green box, they then talk to the voices, stay in their room and isolate the bottom right blue box, it makes them feel very scared and hopeless. And because this is a longitudinal formulation, it's allowing us to sort of see the development of this over time. We know this individual has had experiences where they were struggling in school, struggling in inverted commas because of their interpretation of that experience. The high academic expectation from their family, that they were bullied at school and there were themes of protectionism in the family. They've all led to these beliefs about themselves of being powerless, links very clearly to the bullying perhaps, and I'm a failure, the academic performance expectation conflict. So all of this is really sort of developed to help us then put this together in a way that's hopefully meaningful to the individual, it should be meaningful, they're the ones that's really driving the development of this. And then that tells us where we can potentially intervene. Next slide, please. Which would take us into the application of intervention and skill building. It was very much informed by our formulation, drawing upon cognitive and behavioral interventions. So for instance, we might be doing things around coping skills for the voices, we might be wanting to do some cognitive restructuring or developing alternative thoughts or that interpretation about being, that the voices have more control than the individual does. We might want to do some work around the schema, for example, we might want to do some behavioral experiments around the behavior to see what happens if the individual does something, even if the voice is telling them not to. The whole host of different interventions that we can then draw upon as informed by our formulation. And then finally, one of the things that CBTP, I think is very well known for is this idea of homework, that it's very much a doing therapy. Obviously it's a talking therapy, but it's also very much a practice-based therapy. And so it shouldn't just be what we talk about in the session, forget about it, and then come back and talk about it next week, but rather what we talk about in the session, take it home, practice it, try it out, make sure it works. If it doesn't work, come back and tell me, and then we can figure out something new. And within this consolidation of skills is also the wellness planning piece. Next slide, please. And of course, it's absolutely critical that we're able to think about how we incorporate culture into this approach as well. And happily, there's been a number of initiatives recently to really work on culturally adaptive CBT and culturally adaptive CBTP. We can do this in a number of ways through those stages that I've just talked about. One of which is obviously through the assessment and through the questioning of the experiences, which is trying to understand how do these experiences fit with a cultural norm? Where's the distress? What is distressing in this? If somebody's coming and reporting, seeing spirits, for example, and we check in with the family and that's part of their cultural experience, and it's not particularly distressing to the individual, then that is not something we would want to pathologize. If however, that was inconsistent with the individual's culture, then that might be something we would want to explore. We obviously want to integrate key informants in that process, and then ensuring that our individual formulation really integrates a cultural understanding of experiences into the formulation. And then of course, once we're working towards our intervention, that has to be culturally appropriate. And here we can really engage cultural leaders to ensure that the intervention is very much grounded in that individual's culture. How are we doing on time? No, I was going to give you an example, but I shan't. I just want to make sure we carry on. If we've got time, I'll tell you in the Q&A. Next slide, please. Great. So that sets us up for then thinking about how CBT-P and IRT potentially complement each other. And as Piper referred to, this is something that we've really been thinking a lot about with colleagues, particularly out of some work that we did with Cathy Adams and others in Michigan, where there was training already in IRT, but they wanted to add CBTP, which made us think about this is a great opportunity to think about integration of these two approaches. What I really love, I think, about the early psychosis field in general, and this work specifically, is there isn't a need for competition between models. We really want to think about what are the unique features of each of these that can be beneficial, rather than say, this model is better than that model. What we really want to think about is which model is going to work best for the client and the clinicians who are using it. Next slide, please. So out of that work that we did in Michigan, we published a paper last year, I think it was, yes, 2020, the year of COVID, where we described the integration of these two evidence-based practices within coordinated specialty care. And certainly feel free to go ahead and download that if you want to learn a little bit more in depth about the process through which we did that. Next slide, please. We sort of focused really on two primary challenges and thought about possible solutions that this integrated approach can offer us. The first of this is training. So if we just take CBT-P in and of itself as a training model, the last count, which is a little while ago now, 2005, 0.1% of clinicians in the US were trained in CBT-P, tiny amount. I don't have any optimism that that is much larger, despite the fact that I feel like I'm constantly talking about CBT-P and training people. I would doubt that that has got to a level where we're now feeling like we're saturated in CBT-P trained clinicians. So we know that there's a real shortage of people trained in an expert model in this. Of course, this then means limited access for individuals experiencing psychosis to an evidence-based model like CBT-P. In the US as well, there's no standard for CBT training, which means we don't necessarily then have a strong foundation of already CBT trained clinicians where we can just add this sort of specialized piece. So oftentimes coming into a training as a CBT-P trainer, what I'm doing is sort of backing way up and giving people very foundational skills in CBT first, because unless you have that, we can't really add the psychosis component. For comparison, the training models in England, my accent's probably a bit of a giveaway as to sort of where my background in training and sort of biases lie. The training programs in England for CBT into CBT-P occur over two years. So when I'm coming in with sort of three-day CBT-P training, it's like, oh, we really need people to already be up to scratch for me to add this on top. And oftentimes that isn't the case. So novice coordinator specialty care practitioners who are doing amazing frontline work may not have the foundational therapy skills or basic training that we need in CBT. And of course, there are funding and sustainability challenges. So I'm sure that many of you have experienced, and as trainers, and I experienced, high levels of staff turnover, which makes it then very difficult for programs to really establish sort of a sustainability of evidence-based practice within their service. Next slide, please. So what are some solutions that this integrated approach potentially offers? Well, IRT, as you've seen through Piper's talk, provides this very manualized intervention that's acceptable for novice clinicians, which is fantastic because if the novice clinicians coming in with limited grounding in CBT generally, then they can turn to something that really helps to spell out exactly what they should be doing, which is a really fantastic tool to have. And so what we were thinking about, certainly when we did the work with Michigan, was really thinking about this sort of stepped care training that Insatel described in 2016, where there's a sort of initial foundational training in IRT, but then CBTPS added as an additional component to build psychotherapy expertise. And this starts to ultimately get to what Roth and Hilling talk about as meta-competences, which as we become more expert as clinicians, we're then able to draw upon and switch between either IRT or CBTP, or integrate the two in the work that you're doing, but you're moving to this sort of place of flexible fidelity, but you can only get there when you've demonstrated competence in both of these models. So it's very much a stepped training in this long-term evolution. Next slide, please. Another challenge would be, as Piper alluded to right at the beginning of this, client characteristics. We know clients may be differentially engaged in services initially, and may not be open to a manualized approach. Some clients may need more assertive outreach, more sort of mindful or thoughtful engagement before we sort of present them with a manual. Other people might just eat that up, but if there's only got one option, that's not going to be, not allowing for a whole lot of flexibility. However, clients presenting in very acute distress might benefit from having something very, very structured, and very specific skills and tools to manage symptoms before they go into more of the exploratory work. Similarly, clients have different explanatory frameworks to understand their experiences, and some, as I spoke about earlier, may reject diagnostic labels. But again, if that's the only thing we can offer, we are at risk then of being not only the rejection of the diagnostic label, but the rejection of the service as well by that client. So having alternative ways of thinking about these experiences might be a way of engaging the client. We don't know yet if an integrated IRT CBTP model can be culturally adapted, but that's something we certainly need to work towards. Next slide, please. So having these two models, again, allows for some more flexibility. For those clients presenting in acute distress, it might be that IRT skills are utilized initially to manage symptoms, and this manualized approach then allows clinicians to really support the provision of these skills. Whereas for a client who's very reluctant to engage upfront, there might be this initial befriending period through CBTP, that's kind of that integral first part of CBTP, and then an exploration of meaning of symptoms, and this kind of very curious and more gentle, let's sit on a cover of some fence and think about all these different alternatives if the client's rejecting diagnostic labels. Next slide, please. Oh, references, I am not going to read those. Next slide, please. But they will be in the slide set as you receive them, or rather they will be posted online. And then I put the Navigate website in the chat for folks, but so there's, you know, Piper spoke about the manuals that are available, they're on there. Also training in CBTP, you can access more information on that through Stanford. We also have a North American CBT for Psychosis Network where you can learn more about what we're doing across North America. I think I just hit the time perfectly somehow, I think. Next slide. No, perfect. We're moving into Q&A. I think you wanted to do or say something before we went into Q&A, do you go? Yes, first of all, thank you, Dr. Byer-Calus and Dr. Hardy for a really great presentation this morning. What we want to do is give you the information for how to collect the CEUs that claim credit for today. But first, we also want to thank our partners at SMI Advisor, and they do offer consultation services that you can access. And here's information on how to do that. And to claim credit, and I'm going to put this information in the chat, because this is a bit of a really long URL. You can also take a screenshot of this, which might be helpful. But you would go to this URL, and there's a group ID, it's really long. And this is for claiming credit for the live presentation for today. Just an FYI, you need to have been in the webinar for 60 minutes or longer to claim full credit for today. And our next webinar is coming up really soon by Dr. Oladuni-Oluoe on the experiences of racially diverse families navigating pathways to treatment for early psychosis on June 24, at the same time, 9.30 to 10.30 a.m. Pacific Standard Time, 12.30 to 1.30 p.m. Eastern Time. Okay, so we're going to go back to the claim credit right here. And while we do that, let's jump over to some questions. I saw that you were answering some questions on the chat as well, Piper, but there was one while you were speaking I just wanted to throw out from Andrew. How would you address co-occurring OCD and or bipolar with IRT? So I think one of the things to note is that NAVIGATE was developed for people with early schizophrenia. It doesn't mean that, as you said, co-occurring we can't address. And many times we address it through the coping skills. That is oftentimes one of the biggest places. So whether that be the dealing with negative symptoms module, which is cognitive coping skills, or the coping with symptoms module, which is behavioral-based coping skills, that would be most likely where it would be addressed. It would not be unheard of for people with more persistent or distressing problems that cannot be addressed within NAVIGATE for them to also seek help outside because it is not going to contain all of the necessary tools as well as medications that would be relevant for those specific illnesses. So it's a little bit of some inside and some outside. Thanks, Piper. I'm just looking at the Q&A and a lot of resiliency defined in IRT. That's also a good question. We define resiliency starting in module two, and we talk about it as this ability not only to bounce back but to take note of the skills that you develop as a result of going through a difficult situation. And we talk about it in terms of kind of those skills that you develop and provide some examples of that in module two. And we ask the person to actually think of someone that they know or that they've read about or seen a movie about that they think is resilient, so we begin that process of defining what it looks like from then. It actually continues in the next module, in module three, where they develop their own resiliency narrative of a story that's not necessarily the story of developing the illness for the first time. And then, as I said, it culminates in that processing the episode module. Thank you, Piper. And then there's a question here in the Q&A from Elena asking about resources and how to involve family members in CBTP interventions for young people in CSC. Great question. A whole different talk as well, but certainly when we're doing CBTP training, part of that training is about how do we include natural supports in this, and there's different ways of doing that, you know, either on sort of an ad hoc basis or having them as part of the sessions or utilizing their support through wellness planning or behavioral experiments. So there's a number of ways in which we can really incorporate natural supports. In addition, there is an initiative that I'm working on with Sarah Kapelovich and Doug Turkington at the University of Washington, where we're actually beginning to check out how can we train natural supports, family members, and CBTP skills, not with the intention to make them therapists, that would be a terrible idea, people are busy enough already, but so that they have some skills to fall back on when they're supporting their young one and some knowledge about psychosis. So kind of a psychoeducational approach, but very focused on drawing upon CBTP skills. So we can certainly send information about that as well. And then Elaine, you're asking how to address individuals when they're having difficulty with formulation meaning making because the level of distress is so high, are they stuck in a trauma reaction? So I'd say if the level of distress is so high when they're starting the sessions with us, or you know, they're starting the treatment, this is again a good example of where utilizing IRT skills to help manage distress would be something we would want to put in place first, before we move into that meaning making trauma piece. And then we might want to draw upon sort of, and again, whole different training in and of itself, which is how do we incorporate trauma and understanding of trauma and trauma interventions into CBTP, a lot of work being done around that at the moment. But that's when we would want to go into a protocol that was very much focused on that intervention. So Kate, I saw a question in here asking if we have any videos or demonstrations of IRT and CBTP. I would tell you on the navigate consultants.org website are a series of video demonstrations of IRT sessions. So it's nice because it's all contained there for you. But Kate, do you have any for CBTP? Oh goodness, I wish I had more. There are some, so I can, let me see, I could put you some links. So hang on. So the one thing, so would you mind putting the link again to the navigate consultant? Sure, I can do that. Because I know Lydia in the Q&A is also asking the same. And if I manage to stop talking long enough, I will put in some things from the psychosis research unit at Manchester. One of my jobs for this year, which I see is vastly running out, because we're halfway through it already, is to try and actually get some funding to film some more CBTP interactions. There are some from the UK, when I share with them in trainings, people say, I can't understand the accent. People, you're not watching enough Downton Abbey, frankly. So I need to make some that are a little bit more culturally relevant for this country. But so there are some that exist. If I stop talking long enough, I'll put those in there. I answered Lydia's question. I want to go to your question, Andrew, of like, how do you CBTP for something like reptilian conspiracy theories? And I loved that question. It is such, it's such a challenge right now. There is, again, like, Piper's probably the same. Many of you are probably the same. I'm geeking out slightly on what we're seeing in terms of this rise of conspiracy theory, and all of the conversation then about, well, how do conspiracy theories really differ from delusions? Are we talking about the same thing? Are we talking about something entirely different? If so, what's the line or the threshold for treatment? So it's a really big challenge that I think is addressed, you know, kind of we're facing right now. How would I want to use CBTP for something like reptilian conspiracy theory? The challenge here with conspiracy theories are that individuals are rarely help-seeking, right? They're part of a subculture where they're finding a lot of support for their beliefs, and may or may not be distressed by them. So first and foremost, it would be a lot of befriending and engagement to really work with that person to get to a point where they would be willing to sit and start to think about other opportunities or other possibilities for how they're seeing the world. But upfront, there would have to be a lot of that sort of pre-intervention engagement. This is certainly not somebody who would respond well to just receiving a diagnosis, and probably no one would want to provide a diagnosis in this instance. So yeah, I don't know if I answered the question very well. Let me see. I know we had another question around how to work with people who have the co-occurring substance use problems. And I think it is a really important question because many, many individuals that we work with in early psychosis are concurrently using something like cannabis or alcohol in particular. Those are the ones that typically show up. I will tell you that we have been thinking about this really heavily in IRT, and it really led to this reformulation in some respects of the new version of IRT and the updated version of the substance use module. And so it is something that we do no matter what. It doesn't matter if they're still using. We still see them in IRT. What we do is we provide some basic education as early as possible. So we've moved up some basic substance use education to the education about psychosis module. So it's already built into there. We put in some regular check-ins around substance use so that you're always, it's an ongoing part of treatment, that knowing about that, asking about that is an ongoing part of treatment. And then we re-envisioned the module itself to better reflect the developmental stage that many of these young individuals are at. So we put it in this idea around behavioral experiments and ways to normalize it. So you'll notice it starts out talking about wellness and engaging in more exercise and kind of healthy behaviors, and then talks about strengths and resiliency before we move to those strategies to help people cut down or stop using. So it's all couched in this idea around behavioral experiments that are really built into the manual and the modules and the handouts. So you can see that as a way for people to try it out. And it doesn't mean that they have to do it forever, which is often very much more appealing to young people that we found so far. So I just wanted to, and Kate, what would you say on the CBT for psychosis in? Oh, I'm going to answer that. I'm still stuck on reptilian conspiracy theory because I still want to come back to that too. Very much similar to any conspiracy theories, but very much kind of, again, I think this really speaks to that possibility for integration because it's very similar in the ways of, unfortunately, despite having good evidence base for CBT-P, the trials that have looked at integrated substance use interventions and CBT-P have been less successful. So it does speak to the need to really develop something that's more robust and that is culturally informed in the way that it is youth-oriented and it's not just this stop doing it forever because that's just going to get dismissed. But back to the reptiles just really quickly because I have to go there. We know from conspiracy theories that there are risk factors associated with a kind of a contagion of conspiracy theories. So it's something that we could, there's something that we certainly could be formulating with an individual. And I think one of the things that is really helpful for us as clinicians using IRT, using CBT-P, using narrative therapy, whatever, is to look at the function of the balloon, right? If we come in just seeing this purely as a symptom that we need to eradicate through medications, we're missing the meaning and the richness of why that belief might have developed. I don't know if any of you've seen Underground Railway on Amazon that's kind of recently been released. If you haven't, I highly recommend it. Take it slow. But in there, I think one of the second to last, I think it was, episodes of this beautiful line that sometimes a useful delusion or helpful delusion is better than a useless truth. And I think that's such an important thing for us to hold on to when we're working with individuals with what we might term a delusion or a conspiracy theory, is to understand what is the function and the utility of that belief to the individual and what it's replacing that might feel unhelpful. So that might be also a tact that I would take as I was exploring conspiracy theories. Yes, I've totally taken you into a totally different direction. That is perfectly okay. I don't know how much more time we have. I think we're probably at our limit would be my guess. A couple more minutes. Okay. I know when I was making notes, Kate, and so I know another question that came up was about the use of these interventions on inpatient units and whether or not we have any information about the ability to reduce hospitalizations and whether or not they need to be shortened. I will say that we have not done IRT on an inpatient unit. I think it would need to be significantly adapted, partly because coming from a CBT framework, we expect people to have time to go back and practice, like similar to what Kate was talking about. And when you're on an inpatient unit, you're meeting every day, sometimes more than once a day. So you not only need to think about what topics can get covered in such a short amount of time, but also what do you do about that shorter time to be able to practice things. So that, I mean, and I don't know on the CBT for psychosis side, Kate, if you have any information. Yeah. So it has been adapted and utilized on inpatient settings. Our inpatient unit at Stanford, we did training as well. It tends to be more skills-based just because of the nature of the stay on an inpatient unit is shorter. And so we've been training nurses, case managers, our psychologists are trained in full CBTP on the unit, but in what's called CBTP-informed skills. So there's certainly some evidence for the effectiveness of this. Somebody also asked very early on about recovery-oriented cognitive therapy. And again, that's been something that has been applied in early psychosis. It's been applied in middle-year settings, such as locked units, very much falls under the umbrella of CBTP and has some additional benefits for sure. I'm also seeing a question here about IRT and CBTP as effective for people beyond the first episode. And I'll speak to the IRT piece, but there's, again, certainly CBTP was initially developed and was focused on individuals who had been experiencing psychosis for longer than first episode psychosis, longer than the first episode, sorry. So there's definitely ways in which we can utilize this information and these interventions to support people with maybe a longer standing history of psychotic symptoms, and it'd still be incredibly helpful. So for example, I'm training clinicians in two of the state hospitals here in California, and typically the individuals that are housed in those state hospitals have been experiencing psychosis for a significant amount of time. And we're certainly seeing real benefits from being able to access this intervention, which has been really fun, but I'll hand over to you, Kai, to talk about the IRT piece. Yeah, and so I will say that we don't have any evidence that you could, that this would be effective after that first episode of psychosis. However, the way that we developed IRT was from existing interventions that were supporting people with longer-term multi-episode schizophrenia. So it really does have all of those elements in one package, right? That's where it comes from, illness management and recovery, the positive psychology elements, the CBT elements. So they're all really built in there, what we already knew. What's different about IRT is it really puts the lens in perspective around language, around approach, around all the way that it's set up, if you're experiencing this early on. So the difference is if you're doing it with somebody who's had the illness for a long amount of time, you may want to adjust some of the way that it's worded, because it's really worded for that younger kind of audience, as well as people with less experience with their illness. So there's parts of it I know, anecdotally, clinicians have really applied. I just don't have any evidence that really supports that, except that it comes from, you know, it was really developed from existing interventions.

Individual Resiliency Training

Cognitive Behavioral Therapy for Psychosis

Early psychosis

Coordinated specialty care

Therapeutic rapport

Collaborative exploration

Training and cultural adaptation

Co-occurring disorders

Involvement of family members

High distress levels

Adapting interventions