1. PROFESSOR RONA MOSS-MORRIS ADHERENCE TO PSYCHOLOGICAL INTERVENTIONS IN MS

2. ISSUES TO CONSIDER IN CLINICAL TRIALS AND PRACTICE 1.Person affection by MS (paMS) presenting for initial session 2.paMS attendance at sessions 3.paMS completion of homework or practice tasks. 4.Therapist adherence to therapy protocol (treatment fidelity)

3. 1. PRESENTING FOR THE INITIAL SESSION Stigma of psychology/mental health Integrated care versus separate physical and mental health services. Importance of referral ‘Psychology as last port of call’ ‘Nothing else I can do….’ After first session – maintaining paMS in sessions engagement relevance of treatment model for MS collaborative approach

4. 2. ATTENDANCE AT SESSIONS.

7. CBT FOR MS ADJUSTMENT 1.Introduction to adjusting to MS 2.Adapting to living with MS 3.Setting goals and problem solving 4.Managing symptoms 5.How to tackle negative and unhelpful thoughts 6.Improving the quality of your sleep 7.Managing stress 8.Managing social relationships 9.Preparing for the future

8. BASELINE ASSESSMENT n=94 RANDOMISATION 8 SESSIONS CBT n=48 15 WEEKS FOLLOW UP n=47 6 MONTH FOLLOW UP n=46 12 MONTH FOLLOW UP n=45 IN-DEPTH INTERVIEW n=15 8 SESSIONS SUPP. LISTENING n=46 15 WEEKS FOLLOW UP n=42 6 MONTH FOLLOW UP n=39 12 MONTH FOLLOW UP n=45 IN-DEPTH INTERVIEW n=15 CONSENTED N=122 RANDOMISATION 8 not eligible 10 changed their minds

9. PRIMARY OUTCOME MEASURES General Health Questionnaire (GHQ-12, Goldberg, 1992) improvements in both groups but changes in CBT significantly greater than in SL at end of treatment and 12 months follow-up Work and Social Adjustment Scale (WSAS, Mundt et al., 2002) greater improvement in CBT group but differences not significant.

10. ADHERENCE TO SESSIONS COMPLETED 85% of trial participants completed all 8 sessions CBT – 7 participants (14.6%) dropped out before completing all eight sessions SL – 7 participants (15.2%) Reasons too busy finding therapy unhelpful or not useful feeling they had already gained benefit.

11. CHANGE IN GHQ MODERATED BY SESSIONS COMPLETED

13. CHANGE IN WSAS MODERATED BY SESSIONS COMPLETED

14. 3. HOMEWORK

15. HOMEWORK IN COGNITIVE BEHAVIOURAL THERAPY Homework tasks are a core and crucial feature of CBT planned therapeutic activities undertaken by clients between sessions Based on content from the cognitive behavioural model but individualised to client formulation designed collaboratively (Kazantzis et al., 2005)

16. PURPOSE OF HOMEWORK TASKS Self assess thoughts, moods, physiology and behaviours Allow clients to experience behavioural and cognitive change in vivo Experiment with new behaviours Practice and maintain new skills or techniques (Judith Beck, 1995)

17. META-ANALYSIS OF EFFECTS OF HOMEWORK TASKS ON TRIAL OUTCOME 27 psychotherapy studies of mental health conditions. Effects size on treatment outcome inclusion of homework tasks (.36) compliance with those tasks (.22) (Kazantzis, Deane, & Ronan, 2000) Is it about quality (i.e. doing the homework correctly) or quantity

18. HOMEWORK RATINGS Completed each session by therapists 1 – 10 scale of how well patients completed homework Significantly predicted improvements in WSAS at 12 months, but not GHQ

20. 15 – 20% OF THE POPULATION SUFFER FROM IBS Symptoms abdominal pain or discomfort altered stool frequency altered stool form altered stool passage abdominal bloating

22. GLOBAL RATINGS OF RELIEF: INTENTION- TO-TREAT (N=64)

23. Change in IBS-SSS across Groups

24. ADHERENCE TO AMOUNT OF HOMEWORK Only 1 out of 30 self management patients did not complete therapy 24 out of the 30 (80%) participants in the self- management group returned their homework sheets. Quantity score – number of sheets completed The mean score for the quantity completed was 6.94 (S.D.=2.66) out of a total of 10 sheets.

25. QUALITY SCORE Generated an ideal formulation for each of the homework tasks following Schmidt and Woolaway- Bickel (2000) e.g. an ideal answer for goals around bowel symptom management. the goal was specific to time, place, frequency the participant set realistic goals for each area the participant completed self-monitoring of goals Rating done by two independent raters (kappa.64)

27. CONCLUSIONS Adherence of paMS does affect outcome in CBT based treatments. For therapist delivered CBT – number of sessions completed is important Homework appears important for improvements at longer term follow up, particularly for impact of MS on life roles For self-management based on CBT – completing homework (quantity and quality) is associated with better outcome in IBS.