Promoting psychological interventions in psychosis: the NSW Tertiary Referral Service for Psychosis

ABSTRACT Experience of psychotic illness has an enduring impact on a person’s life, relationships and function. International guidelines recognise the importance of psychological interventions alongside pharmacological strategies in improving outcomes for people living with psychosis, including cognitive remediation therapy (CRT) and CBT for psychosis (CBTp). The Tertiary Referral Service for Psychosis (TRSP) is a publicly funded mental health service, consisting of a multidisciplinary team that utilises a biopsychosocial framework to inform holistic evidence-based recommendations tailored to an individual’s goals, including access to psychological therapies. In this commentary, we introduce the TRSP, and describe its origins and development. We detail the complementary roles and specific expertise of the clinicians involved within the TRSP multidisciplinary team. We highlight a key aspiration of the service: to routinely promote the use of evidence-based psychological interventions in addition to pharmacological treatment. We summarise the evidence base for these psychological therapies both in improving function and in reducing distressing symptoms in psychosis. Finally, we describe the challenges faced by the TRSP to date in aspiring to promote routine access to psychological interventions in psychosis. Key Points What is already known about this topic: (1) Psychotic illness is often chronic. Distressing experiences such as auditory hallucinations can persist despite antipsychotic treatment. (2) Many people living with psychosis experience cognitive and functional impairment, which often goes unaddressed. (3) Evidence-based psychological interventions exist which improve function and reduce distressing symptoms and cognitive impairment, but access to skilled clinicians is limited in Australia. What this topic adds: (1) Summarises the evidence base for psychological interventions such as cognitive remediation therapy and cognitive behavioural therapy for psychosis. (2) Introduces the NSW Tertiary Referral Service for Psychosis as an example of a multidisciplinary team providing holistic recovery-based care utilising psychological interventions alongside pharmacological treatment. (3) Discusses the challenges faced in promoting the need for greater access to psychological interventions as part of a holistic recovery-based approach to care.


Introduction
Experience of psychotic illness has an enduring impact on a person's life, relationships and function (Lappin et al., 2016).Many people will experience a chronic illness course marked by multiple relapses while others may have continuous distressing symptoms despite receiving antipsychotic treatment.(Dazzan et al., 2020).Over recent decades, a rigorous evidence base has been established for the effectiveness of psychological interventions (for instance, Cognitive Behaviour Therapy for Psychosis (CBTp), Cognitive Remediation Therapy (CRT)) in reducing relapse and improving function in people living with psychosis.Despite this, there is minimal access to these therapies in public mental health services in Australia (Morgan et al., 2021).The New South Wales (NSW) Tertiary Referral Service for Psychosis (TRSP) is a multi-disciplinary team that aims to provide holistic care to people living with psychosis.Adopting a recovery-oriented approach that goes beyond symptom-reduction to provide personalised support for the individual to work towards their goals, the TRSP promotes the use of evidence-based psychological recommendations alongside pharmacological strategies.

TRSP: background and service description
The TRSP is a state-wide service which aspires to improve the lives of people living with complex psychosis.The TRSP is NSW only specialised tertiary referral psychosis service, operational since June 2020.The establishment of the TRSP occurred following an informal consultation and scoping exercise with experts working in public mental health services in NSW in the area of complex psychosis, which identified that NSW clinicians reported a huge challenge in accessing clinical review which added value to the management of individuals living with complex psychosis.A TRSP pilot was made possible by NSW Health funding, with further grants received to sustain the project from NSW Health and the Mindgardens Neuroscience Network.The TRSP provides specialised support to adult public mental health services through a consultation model (i.e., provides advice to an individual's treating team but does not take over care).Beyond the clinical service discussed here, TRSP also delivers professional education and training in higher level clinical skills, family and community engagement, and clinical effectiveness and investigative research.
The TRSP is hosted by South Eastern Sydney Local Health District, with a three-day weekly clinic delivered face-to-face or via telehealth at the Prince of Wales Hospital, Sydney.Referrals are received from across NSW public mental health services.Eligibility criteria and operational criteria for referral are listed in Table 1.The choice of terminology "complex psychosis" was purposively broad in scope, reflecting the team's capacity to work not only with people whose psychotic illness has been complicated by partial, limited or no response to treatment but also with those who have significant comorbidities such as substance misuse, epilepsy, intellectual disability, personality disorder, complex trauma, and other physical and mental health difficulties (National Institute for Health and Care Excellence, 2020).

TRSP assessment and formulation
Underpinned by recovery principles, the TRSP team employs a multidisciplinary approach to support individuals experiencing complex psychosis (Table 2).A biopsychosocial framework is applied which enables the consideration of multiple risk factors which contribute to the development and maintenance of distressing psychotic experiences.In recognition of the lasting mental health impacts of trauma (Sara & Lappin, 2017), and the potential for health services to re-traumatise, all assessments are conducted in a trauma-informed way.At a multi-disciplinary team formulation, key concerns are identified, with a view to considering evidence-based interventions which may be of benefit.The TRSP involves the consumer, carers and referring clinicians in the development of holistic evidence-based recommendations for future treatment and agreed goals are developed into a collaborative care plan.

TRSP psychological intervention recommendations
Antipsychotic medication remains a mainstay in the treatment of psychosis and pharmacological • consideration of rarely used specialised treatments (e.g., immunotherapy) • continuous hospitalisation of long duration • failure to respond to an adequate trial of clozapine and to psychosocial therapies recommendations are core to TRSP care (Lappin et al., 2022).There is increasing recognition by clinicians and the wider community, however, that pharmacotherapy alone is limited in its ability to target key issues such as cognitive and negative symptoms, decreased sociooccupational function and social exclusion.There is an established evidence base to support the use of psychological and psychosocial interventions in symptomatic, social and occupational recovery in psychosis (Frawley et al., 2021;Wykes et al., 2008Wykes et al., , 2011)).The strong evidence base for CRT and CBTp is summarised in Box 1.The potential benefit of recommending these psychological interventions is considered for every individual.Specifically, where it is identified that an individual is experiencing cognitive and functional difficulties which indicate potential benefit from cognitive remediation therapy, this is included as a TRSP recommendation.
Similarly, where an individual reports distressing psychotic experiences such as hallucinations and delusions or other issues related to psychotic experiences, recommendation will be made to refer for CBTp.Other indications for referral for psychological support may include, but are not limited to, severe anxiety, depressed mood or panic, obsessive and compulsive issues, and dealing with traumatic experiences and adverse life events including domestic violence.Finally, where indicated, referral for family work or family intervention will be recommended.
In light of the literature on the availability of psychological therapies for people experiencing complex psychosis, a retrospective case note review was conducted to examine the proportion of individuals engaged with the TRSP who had previously accessed evidenced based psychological therapies (i.e., CBTp and CRT).This project was reviewed and approved as a quality improvement project by South-Eastern Sydney Local Health District (Ref: T20/81560).The review included all individuals undergoing multidisciplinary team assessments with the TRSP between 22nd June 2020 and 21 st June 2022.Information on prior The clinical neuropsychologist role within TRSP includes assessment, intervention and education elements.As part of the TRSP assessment process, the neuropsychologist will undertake a standardised neuropsychological battery with all appropriate clients, evaluating the cognitive domains typically affected in psychosis.In collaboration with the TRSP team, these cognitive test results are synthesised with the outcomes from the multi-disciplinary assessments and fed back to the treating team and client in clear, jargon-free language.The neuropsychologist also provides training to clinicians and services regarding the assessment of cognitive impairment in psychosis, and co-ordinates the cognitive remediation groups and the "cognitive remediation training for clinicians" project.Consultant Psychiatrist/ Psychiatry Trainee The psychiatry trainee conducts a thorough file review with a specific focus on illness onset, early illness and response to treatment.Completing this involves liaising with the referring team, accessing medical records and collecting information from family and other supports.The consultant psychiatrist and trainee assess each client, face-to-face or via telehealth, using a combination of gold-standard clinical assessment and standardised measures to define psychosis and comorbidity diagnoses, key concerns and openness to a range of potential future interventions.These assessments and those of the whole team are discussed to derive a multidisciplinary formulation which is then integrated by the trainee into a structured presentation.This is shared with the treating team at a case conference in order to facilitate discussion around best-practice evidence-based future interventions that are feasible to deliver in the MHS setting.Peer Support Worker The peer support worker uses a lived experience perspective to support the clients who access the TRSP.Through sharing their own personal story of recovery in a purposeful and meaningful way, the peer support worker aims to provide hope and examples of demonstrating strengths and purpose.
During the assessment process, the peer support worker will regularly communicate with clients to understand how they are feeling about the assessment process and whether they have any concerns or issues they wanted to voice.
A recovery assessment tool is completed with clients to identify areas in which they feel they are doing well and those where further support may be beneficial.

Social Worker
Clinical social workers in MHS hold diverse roles that take into account the systems, environment and societal factors impacting an individual.The TRSP social worker applies this holistic framework when working with clients and their families/supports through assessment, provision of psychoeducation and suitable interventions.A complete psychosocial assessment is undertaken with clients, with focus on their life experiences, trauma, adversity, current and future needs.Standardised measures are used in conjunction with clinical assessment for clients and their identified carer or family member.The family assessment is informed by a biopsychosocial approach which includes a thorough developmental history, identification of key concerns and needs.Occupational Therapist Occupational Therapists assist clients to determine their functional support needs, to engage in meaningful activities, to identify goals, and to support them to work towards achieving these.The TRSP occupational therapist (OT) role comprises assessment, intervention, and education to clients and their identified supports.The OT completes a comprehensive psychosocial assessment with standardised assessments which assist in eliciting meaningful goals and developing knowledge on how to tailor supports for successful goal attainment.Education is provided to the client and their supports on recommendations such as goal attainment strategies, level of functional support required including breakdown of tasks, and ensuring engagement in meaningful activities to promote recovery and independence.OT principles are aligned with strengths-based, recovery-oriented practice, and above all, recognising meaningful occupations and roles as essential to healthy, fulfilling lives.
treatment is collected by the psychiatrist during a clinical interview and, along with all assessment data, is recorded in a secure online database.Data relevant to this review were extracted from this database and are summarised descriptively below.During this period, 52 individuals were assessed, of whom three-quarters (n = 38) had treatment resistant illness (Lappin et al., 2022).Overall, the group had moderate global clinical impairment and experienced a high level of positive symptoms (markedly ill range).Of these, none had ever previously received CRT and just one individual had ever previously received CBTp.TRSP recommendations for psychological interventions were made for 48.0%(n = 25) of individuals.Of these, 32.0% (n = 8) of the recommendations were for CRT and 36.0%(n = 9) were for CBTp.

Enabling greater access to psychological interventions through TRSP
There is an established evidence base to support the use of psychological and psychosocial interventions in symptomatic, social and occupational recovery in psychosis (Frawley et al., 2021;Wykes et al., 2008Wykes et al., , 2011)).In TRSP, we have focused on first introducing those individualised treatments which have a robust evidence base: CRT and CBTp (Box 1).Importantly, this evidence suggests that individuals who are less severely unwell are most likely to achieve benefit from therapy (Bighelli et al., 2018) and complete therapy (Altman et al., 2022).
Multiple individuals seen in TRSP were too severely unwell to engage in CBTp or CRT, while others had comorbid intellectual disabilities which rendered them ineligible.Nonetheless, there remained a high number of individuals who had been treated in mental health services for many years without receipt of evidencebased targeted psychological intervention.
International and Australian guidelines for the management of psychosis recommend that CBTp be offered routinely and that cognitive remediation therapy should be offered to all who have cognitive impairment (Galletly et al., 2016).Current availability in Australian public health systems, however, is vanishingly scarce, limited by lack of access to trained therapists.There is a need for opportunities to develop networks which better enable access to these therapies with the ultimate aim that they should become routinely available to individuals living with psychosis.This is a key aim for TRSP, as outlined below.
The TRSP aims to promote the use of psychological interventions in the routine care of people living with psychosis.The TRSP aspires to achieve this not only through recommendations made through the clinical service, but also through the delivery of programmes of training for clinicians and through novel research.The key aim here is to increase confidence and knowledge of mental health professionals to support people experiencing complex psychosis with evidence-based holistic interventions.

Cognitive remediation therapy
Individuals living with psychosis can show a range of impairments in neurocognitive abilities -such as memory, attention, social cognition and executive function -which are often evident early in the illness course (Kravariti et al., 2009(Kravariti et al., , 2019) ) and which are strongly predictive of impaired psychosocial function (Bowie & Harvey, 2006).Cognitive remediation is the umbrella term given to a range of psychological treatments based in behavioural training which are designed to improve neurocognitive abilities in an enduring fashion that enables generalisability to day-to-day tasks (Wykes et al., 2011).Thus, the goal of cognitive remediation therapy (CRT) is to improve everyday functioning in people living with psychosis by improving cognitive processes.CRT enables participants to develop an understanding of their cognitive strengths and limitations and to enhance their ability to use problem solving in everyday activities, vocational/occupational and social activities.Several modes of delivery exist, including pen-andpaper approaches and computer presentation programmes such as CIRCuiTS (Reeder et al., 2017;Thomas & Rusten, 2019).
There is meta-analytic evidence that cognitive remediation is an effective treatment in improving cognitive function in people with schizophrenia and related psychoses (Kambeitz-Ilankovic et al., 2019;Lejeune et al., 2021;Vita et al., 2021;Wykes et al., 2011), with the strongest effect sizes seen for improvements in cognitive performance (Cohen's d = 0.28-0.45)and psycho-social functioning (d = 0.16-0.42)and an additional, though smaller, effect (d = 0.10-0.18) in reducing symptom severity.Elements that are known to be associated with greater effectiveness of CRT include the involvement of an active and trained therapist; a structured approach to the development of cognitive strategies, and provision in the context of a rehabilitation setting, where participants have the opportunity to put their training into practice through, for example, bridging exercises (Vita et al., 2021).Importantly, cognitive remediation can be effective regardless of age or duration of illness and so is a valuable treatment to consider in people living with chronic psychosis (Vita et al., 2021).CBTp CBT for people with psychosis (CBTp) has emerged as an evidenced-based treatment for psychotic experiences such as auditory hallucinations and delusions when employed in addition to treatment as usual (Wykes et al., 2008).CBTp aims to enable individuals both to re-appraise experiences of psychosis and to reduce the distress associated with psychotic experiences (Birchwood & Trower, 2006).CBTp is more effective than other talking therapies such as supportive counselling for auditory hallucinations (van der Gaag et al., 2014), with meta-analytic effect size = 0.40 [95% confidence interval CI = 0.252, 0.548] (Wykes et al., 2008).CBT is significantly superior in reducing positive symptoms when compared to an inactive control condition (standardised mean difference, SMD = −0.29;95% CI: -0.55 to −0.03), or to treatment as usual (SMD = −0.30;95% CI: -0.45 to −0.14) or to supportive therapy (SMD = −0.47;95% CI: -0.91 to −0.03) (Bighelli et al., 2018).There is good evidence that CBTp is effective in reducing delusions, though the effect size is smaller, comparable to that seen in other interventions such as befriending (approximately Cohen's d = 0•3) (Freeman et al., 2021).Finally, while positive symptoms were the initial targets of CBTp, there is also evidence for its application to help manage negative symptoms and for comorbid depression, anxiety and substance use (Wykes et al., 2008).
To date, the TRSP has delivered a programme of training in cognitive remediation therapy, including initial skill development and ongoing supervision to clinicians working with individuals with complex psychosis in NSW public mental health services.This builds on work pioneered in regional NSW public mental health services by Thomas and co-workers (Thomas & Rusten, 2019) which demonstrated the feasibility of CRT training and delivery in public mental health services in regional NSW.Broader aims are to expand the number of clinicians who train and develop expertise in CRT delivery so this evidencebased treatment can become more routinely available throughout mental health services.Future aims include the delivery of a similar programme of training in CBTp, which will be enabled by the inclusion of a clinical psychologist with CBTp expertise in the TRSP team.
There are multiple challenges faced in the implementation of psychological therapies in Australia.An important consideration is the need for supervision by those trained and expert in CRT or CBTp.This is a significant barrier in mental health services not only here in Australia but also globally (Wykes et al., 2008).A further concern is that research funders may assume that studies investigating CRT or CBTp are no longer needed, as there is now an established evidence base of their effectiveness.While this is true in the setting of a research study paradigm, work is still needed to understand how best to implement sustainable delivery of therapy.Key challenges include commitment by health managers, team leaders and clinicians to dedicate resources (time and money) for training and delivery of these therapies in routine care.

Future directions
Future aims of the TRSP include conducting research trials to demonstrate the evidence base in the Australian context for the feasibility and effectiveness of offering emerging psychological interventions to people living with complex psychosis.These include AVATAR therapy (Craig et al., 2018), SlowMo (Garety et al., 2021) and the Feeling Safe Programme (Freeman et al., 2021).AVATAR therapy enables people who hear voices to engage in dialogue with a digital representation (avatar) of the voice-holder.This dialogue is supported by coaching by a trained therapist, with the avatar over time responding by becoming less hostile and losing its power.The brief targeted therapy has been shown to reduce the severity of auditory hallucinations (Craig et al., 2018).SlowMo is a brief blended digital therapy designed to target reasoning processes which contribute to paranoia, for example jumping to conclusions and inflexibility in beliefs.SlowMo assists the user to develop awareness of these reasoning biases with benefits of reduced paranoia and improved quality of life (Garety et al., 2021).The Feeling Safe Programme was developed based on the recognised need for more effective therapies for persecutory delusions.This cognitive therapy employs a range of modules (e.g., feeling safe enough, improving sleep, improving self-confidence, reducing worry, and reducing voices' impact) delivered over approximately 6 months/20 sessions and showed large and significant reductions in persecutory delusions (Freeman et al., 2021).As with all emerging therapies, there is need for confirmation of effectiveness through welldesigned randomised trials, and it will be important in the Australian context to understand factors that impact feasibility of delivery.
Finally, TRSP endeavours to collaborate widely with clinicians, service providers, consumers and the community at large in order to develop networks which advocate for improved access to psychological interventions for individuals living with complex psychosis.Ultimately, this will enable our goal to deliver a higher standard of holistic care for those living with psychosis in Australia.

Box 1 .
Evidence for Cognitive Remediation Therapy and CBTp.

Table 1 .
TRSP eligibility criteria and operational criteria for referral.