Exploring the implementation of cognitive behaviour therapy for psychosis using the Normalization Process Theory framework

Abstract

Objective: Evidence suggests that only a minority of service users experiencing psychosis have access to Cognitive Behavioural Therapy for psychosis (CBTp). Normalization Process Theory (NPT) is a theoretical framework which focuses on processes by which interventions are implemented and normalized in clinical practice. This study explored the views and experiences of mental health professionals regarding the implementation of CBTp. Barriers and facilitators to implementation were explored using the NPT framework.

Design: A qualitative methodology was adopted involving semi-structured focus groups and individual interviews.

Methods: A total of 14 members of staff working in the community and crisis mental health teams were recruited. Thematic analysis was used to generate initial themes. The framework approach was utilized to map initial themes to the NPT framework.

Results: Inductive coding generated five overarching themes consisting of 15 individual subthemes which captured the perceived barriers to engagement; contextual barriers to implementation; optimization of implementation; positive attitudes towards implementation; and expectations of implementing CBTp. All but two subthemes mapped on to the NPT framework. The deductive analysis suggested that difficulties in making sense of CBTp among professionals were reflected as service level barriers which impeded wider implementation.

Conclusion: The results of this study suggested a mixture of barriers and facilitators to CBTp implementation. Interpreting our findings within an NPT framework indicates the importance of strong clinical leadership to address difficulties in sense-making and service investment in CBTp.

Practitioner points: Findings indicate a mixture of barriers and facilitators to CBTp implementation. NPT analysis indicates difficulties in coherence among stakeholders regarding the purpose and value of CBTp. Difficulties making sense of CBTp translates into service level barriers and impede the collective action of stakeholders. The role of clinical leadership is crucial in increasing coherence and collective action in services.

Keywords: barriers; cognitive behaviour therapy; cognitive behaviour therapy for psychosis; experiences; facilitators; implementation; implementation framework; mental health professionals; normalisation process theory; psychosis; views.