The process of introducing CORE-OM into the practice of a specialist psychotherapy service

1. The process of introducing CORE-OM into the practice of a specialist psychotherapy service Mark Aveline, Terri Eynon, Rebecca Cashmore, Mark McCartney, Ian Shaw Nottingham Psychotherapy Unit, UK

2. Context • NHS plan, July 2000 • ….to offer people fast and convenient care delivered to a consistently high standard. Services will be available when people require them, tailored to their individual needs. • UK emphasis on • Evidence-based practice • Bench marking • Quality assurance • One goal: routinely collected data that will shape clinical care and subsequent service plans

3. Reality • No universal acclaim for existing measures • Few meet Slade et al’s (1999) feasibility criteria: brief, simple, relevant, acceptable, available & valuable • Often conflict with existing measuring practice, with model of therapy, with model specific outcomes & over inadequate administrative support

4. 18/12 profile of two linked services using CORE-OM • CORE-OM • 34 item self-report questionnaire • Total score + sub-domains for subjective well-being, problems/symptoms, life functioning and risk to self & others • Nottingham Psychotherapy Unit • Specialist dynamic and CBT 2o & 3o care NHS service • 450 referrals per year • Integrated • Primary Care Mental Health Service • Newly integrated NHS service of nurses, psychologists & counsellors • 2500 referrals per year • Session maximum = 12 • Grant holders: Mark Aveline, Rosie Hepple

5. Audit Purposes • Profile services • CORE scores, age, sex, ethnicity, occupational status, living arrangements, GP, GP post code • Identify any variations between services & within services • Document therapy intervention and outcome • Devise good ways of presenting CORE scores • Validate CORE as a clinical measure

6. Audit Plan • Both Services administer modified CORE form to all patients over 18/12 period • Beginning & end of assessment • Beginning & end of therapy • Any other time points at clinicians’ choice • CORE end of therapy form • Demographic and referral data also collected • Anticipated yield: 7500 CORE scores • Actual yield: 2500 CORE scores

7. Qualitative study of the process of introduction of CORE-OM • Nottingham Psychotherapy Unit • Experience with HoNOS & GAF • Integrated • CBT: long tradition of using standardised measures as integral part of therapy • Psychodynamic: idiographic & ambivalent • Opportunity to investigate factors in clinicians’ willingness to accept CORE-OM

8. Method • Focus group open to all staff therapists • Depth interviews with staff thought to be representative of CBT and psychodynamic therapists (N =2) • Independent content analysis, informed by Kelly’s Construct Theory (1951). Researchers + independent expert • Consensus discussion probes • Depth interviews (N =2) • Axial coding • Final focus group

9. Results 1 • Respondent 1 (senior, non-medical, psychodynamic) • Central issue = use of CORE as a change in usual way of working • Constructs • comfortable <-> uncomfortable, • symbiotic <-> antagonistic to my usual way of working and • trust <-> mistrust • CORE as foreign object, separate from therapy

10. Results 2 • Respondent 2 (senior, medical, CBT) • No new constructs • Not a change to practice • 'in that it's a generic outcome measure it's different from the things you already do, but in that it's an outcome measure it's very similar to the level of things that you generally do.'

11. Respondent 3 • a psychodynamic therapist, • the category 'separate' was confirmed. • CORE was described as 'an adjunct really, sort of bolt-on' to the therapy’.

12. Respondent 4 • non-medical CBT therapist, lower in the hierarchy, part-time • 'not different', except in that it was generic • more negative about CORE than any of the therapists so far • 'imposed' • 'I still do not understand [CORE]; I can't read it; I don't find the graphs helpful and that is despite me having training for it' • ‘It does not fit nicely with the way I have been used to working and I haven't altered my practice accordingly'

13. Open coding • Central category = comfortableness • Dimension • comfortable <=> uncomfortable • Properties • Coherent with our reality (or not) • Helps us to deal with external reality (or not)

14. Axial coding • Properties and dimensions which interact with the central category • Position • Hierarchy high low • Work pattern full time part-time • Involvement • Relatedness to external world more less • Planning change to CORE in out • Cognitive stance • Theoretical dynamic CBT • Approach accommodation assimilation • Professional identity • Effectiveness secure insecure

16. Conclusions • Action research methodology yields useful qualitative information. Research part of process of change • Findings may not generalise but method does • What have we learnt? • Assimilation not easy for CBT. Accommodation better for dynamic. CORE-OM one part of CORE system. Supplementary to domain-specific measures • Clinical systems slow to change • Active participation in change • Anxiety is the enemy of curiosity • Intelligibility & value encourages adoption • Momentum needs to be maintained