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Cognitive and Behavioral Practice xx (2016) xxx-xxx

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A Model to Transform Psychosis Milieu Treatment Using

CBT-Informed Interventions
Sally E. Riggs, NYC CBTp, Brooklyn, NY
Torrey A. Creed, Aaron T. Beck Psychopathology Research Center, The Raymond and
Ruth Perelman School of Medicine at the University of Pennsylvania

Although CBT for psychosis (CBTp) has been recommended as a best practice since 2002, CBTps availability is quite limited in the
U.S. Integration of CBTp-informed interventions into the milieu of the treatment settings in which the majority of the 2.4 million
Americans with psychosis receive treatment may greatly improve access to those services. This paper presents an evidence-based model for
training line staff in CBTp principles, in order that more staff throughout the U.S. might better support the recovery of people with
psychosis in this way. Examples are provided to illustrate effective strategies and approaches.

Rationale While some evidence suggests that supportive therapy

A PPROXIMATELY 2.4 million American adults, or about
1.1% of the population aged 18 and older in a given
year, are diagnosed with schizophrenia (Robins & Regier,
1991). Treatment and other economic costs due to
schizophrenia are enormous, estimated between D32.5
and D65 billion annually. In 2010, there were approximately
397,200 hospitalizations for schizophrenia nationwide, and
about 88,600 (22.3%) were readmitted within 30 days
(Elixhauser & Steiner, 2013).
Large numbers of individuals with a psychotic disorder
in the U.S. receive psychological treatment solely through
milieu-based interventions such as inpatient units, day
programs, partial hospital programs, assertive community
treatment, and psychosocial club house (Mueser, Deavers,
Penn, & Cassisi, 2013). Many of these programs provide
only group therapy, typically delivered by paraprofes-
sionals, with few psychologists or Ph.D.-level clinicians, and
very rarely are staff trained in evidence-based psycholog-
ical therapies (Kimhy et al., 2013; Mojtabai, Fochtman,
Chang, Kotov, Craig, & Bromet, 2009). Even when more
advanced clinicians are available, the bulk of interactions
that patients have are with direct care or line staff,
who have the least amount of training in how to interact
with people with psychosis or promote their recovery.
Keywords: psychosis; cognitive behavioral therapy; dissemination;
therapeutic milieu; ACCESS model
1077-7229/16/ 2016 Association for Behavioral and Cognitive
Therapies. Published by Elsevier Ltd. All rights reserved.
may lead to clinical gains for this population (Penn,
Mueser, Tarrier, Gloege, & Serrano, 2004), more rigorous,
evidence-based treatments such as CBT for psychosis
may be integrated into these milieu settings to improve
outcomes for the millions of individuals receiving services
(Mueser & Glyn, 2014; Pilling et al., 2002). Directly
training direct care or line staff allows the milieu to move
from a simple safety-net to a therapeutic context in which
all interactions hold the potential for intervention.
Cognitive behavioral therapy (CBT) has been included
in good practice guidelines for the treatment of psychosis in
both the U.K. and the U.S. (APA, 2004; NICE, 2014) based
on the mounting evidence of its efficacy (Gaudiano, 2005;
Grant, Huh, Perivoliotis, Stolar & Beck, 2012; Morrison
et al., 2014; Pilling et al., 2002). Despite these guidelines,
there remains a dearth of appropriately trained mental
health professionals to provide this treatment (Mueser &
Noordsy, 2005; Rollinson et al., 2007). In light of the
scarcity of trained professionals, access to evidence-based
practice remains sorely limited (Jones, 2002). Mueser
and Noordsy (2005) have presented a call to action
for clinical psychologists in the U.S. to design training
programs in CBT for mental health professionals working
with schizophrenia and other severe mental illness, and
the response to that has been rapidly growing. Given that
these services are more likely to be underresourced and
based in community mental health services by milieu line
staff (CDC/NCHS, National Health Interview Survey,
20092013), feasible strategies to implement a response
must reflect the unique strengths and challenges of these
settings.

Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
2 Riggs & Creed
Implementation Process Model
One evidence-based process model for the implemen-
tation of EBPs in community mental health has been
developed with the flexibility to train line staff to deliver
EBP-informed care within the scope of their job roles,
as well as training of more traditional clinicians (Creed,
Stirman, Evans, & Beck, 2014; Riggs, Stirman & Beck,
2012). The ACCESS model was originally developed to
support the implementation of an EBP with therapists in
community mental health (Stirman et al., 2010) and has
been expanded into a 6-step process that can be flexibly
followed with therapists (the Intensive Model) or line staff
(the Milieu Model) to be applied independently or
concurrently based on needs of an organization (Creed
et al., 2014). The two models share the first, fifth, and final
stages of the implementation process, but diverge on the
other three steps to allow for flexible adaptation to a given
setting. The first step, Assess and adapt, focuses on joining
with stakeholders to determine the specific needs of the
setting, as well as facilitators and barriers to the
implementation process. A core training plan is then
adapted to fit the characteristics of the setting. The
second step, Convey the basics, relies on the use of
experiential workshop to build the necessary foundation-
al knowledge for participants. In the Intensive Model,
therapists learn about the cognitive model, case concep-
tualization, engaging individuals in the development of
authentic and personalized goals, and the use of
intervention to help individuals move toward those
goals. In the Milieu Model, experiential workshops focus
on the basics of the cognitive model and basic case
conceptualization to create a shared language and under-
standing among staff, and the development of individuals
personalized goals. These two models differ in that the
Intensive Model prepares therapists with the knowledge
needed to plan and deliver cognitive therapy, whereas
the Milieu Model prepares line staff to use the cognitive
model to inform their day-to-day interactions with in-
dividuals treated in the milieu. During the third step,
Consult, weekly consultations are held with expert
instructors. Therapists in the Intensive Model focus on
applying their new knowledge to individuals in recovery,
helping these individuals move toward their goals
through the use of intervention planning, case conceptu-
alization, and review of work samples. Instructors in the
Milieu Model use scaffolding techniques and feedback
to help line staff build their basic CT-informed skills.
Completion of training and developed skills are assessed
in the fourth step, Evaluate work samples. In the Intensive
Model, competency is assessed based on work sample
review, and observational evaluation is emphasized in the
Milieu Model. During the fifth step of the process, Sustain,
ongoing practice is supported primarily through the uptake
of the EBP by the agency, although the implementation
Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
team provides additional supports as needed through web-
based training, recertification booster training, and other
support as needed. The final step, Study outcomes, em-
phasized the evaluation of the implementation outcomes,
including assessment of the number of behavioral health
professionals trained, retention in training, achieved com-
petency, rates of recertification, and differential outcomes
in web-based and live training.
The ACCESS model has been used to train staff in more
than 40 community mental health programs in cognitive
therapy, ranging from traditional outpatient settings to
nontraditional settings for cognitive therapy such as acute
inpatient care, residential treatment, school-based services,
outreach teams, and safe havens for individuals experienc-
ing chronic homelessness (Creed et al., 2013; Creed et al.,
2014; Pontoski et al., 2016). Approximately 400 clinicians
and 350 line staff have been trained using this model to date
(Creed et al., under review). High rates of retention have
been demonstrated, with fewer than 8% of clinicians
withdrawing or moving to noneligible agency roles.
Participants in the training model have reported
high acceptability of the training process and model, and,
most notably, most clinicians (79.6%) demonstrated a
high standard of competency, commensurate with those
demonstrated in clinical trials of CT (Shaw et al., 1999).
Overview of the Treatment Model
CBTp is based on the basic cognitive model, which
states that our perceptions of our experience shape our
feelings and resulting behavior (J. Beck, 2011). Additional
techniques for engagement and forming a therapeutic
alliance are used, which include making modifications to
traditional session structure and settings, talking about
delusional beliefs empathically and without colluding,
normalizing the symptoms of psychosis, and understand-
ing psychotic symptoms as part of a spectrum exacerbated
by stress, rather than as normal versus abnormal
(Sivec & Montesano, 2012). In addition, CBTp aims to
instill hope, reduce distress caused by psychotic experi-
ence, and improve quality of life. It uses the ABC model
(activating eventbeliefconsequence) to assess beliefs
about psychotic experiences, and uses formulation,
Socratic questioning and guided discovery, cognitive
behavioral change strategies, and homework to bring
about change (Morrison & Barratt, 2010). CBTp skills
and strategies have been successfully delivered in group
settings (Granholm, McQuaid & Holden, 2015; Hill,
Clarke, & Wilson, 2009; Landa et al., 2006; Romme &
Escher, 1989; Wright et al., 2014), which suggests that
transportability to a group therapyoriented milieu may be
appropriate.
Accordingly, there is evidence that brief CBTp inter-
ventions delivered by nontherapists can lead to desirable
client outcomes. Community psychiatric nurses working
 A Model to Transform Psychosis Milieu Treatment
in community mental health teams in the U.K. were
trained to deliver 6 one-hour sessions of individual CBTp
through 10 days of intensive training, followed by indi-
vidual, group, or telephone supervision. Compared with
treatment as usual, individuals who received the CBTp
sessions experienced improvements in symptomatology,
insight, and depression (Turkington, Kingdon & Turner,
2002). At 1-year follow-up, the improvements for insight
were maintained and an improvement in negative symp-
toms was also found (Turkington et al., 2006). Sub-
sequently, case managers in an American community
mental health system received 5 days of training plus
weekly supervision in the same therapeutic approach
(Sivec et al., 2015; Turkington et al., 2014). Case managers
delivered CBTp in 12 meetings with individuals with
schizophrenia, yielding improvement in overall symptom
burden, negative symptoms, depression, anxiety, social
functioning, and self-rated recovery among approximately
60% of participants.
Waller et al. (2013) trained nurses and occupational
therapists over 4 half-days in a specific recovery-oriented
CBTp intervention that utilized graded-exposure and
behavioral techniques. Supervision was given on a fort-
nightly basis and treatment was delivered in eight weekly
individual sessions, targeting anxious avoidance or low-
mood-related inactivity with the aim of achieving a per-
sonal goal. Eleven of the 12 participants achieved their
personal goals and significant improvements were also
reported in depression, clinical distress, activity levels,
negative symptoms, and delusions. Peer specialists, who
have a shared history of recovery and most commonly have
a high school diploma, have also been trained to utilize
CBTp-informed techniques. Perry, Murakami-Brundage,
Grant, and Beck (2013) trained peers in specific strategies
that meshed with their role in recovery, including long-
and short-term goal setting and the use of specific cog-
nitive and behavioral techniques to overcome barriers
to these goals, as well as the basic cognitive model for
conceptualization. Peers reported that the training had
positively influenced their work, improved their confi-
dence for working with people with psychosis, and helped
them to better empathize and engage with their clients
(Perry et al., 2013).
Expanding the focus from line staff to the full treat-
ment milieu, staff in an acute urban inpatient psychi-
atric unit (i.e., nurses, mental health technicians, social
workers, an occupational therapist, a psychologist, and
psychiatrists) were trained in Recovery Oriented Cognitive
Therapy (CT-R). The CT-R model promotes the engage-
ment of people with psychosis in their own treatment, and
fosters staff empathy, compassion, and authenticity through
better understanding of the psychotic experience (Beck,
Rector, Stolar, & Grant, 2009; Chang, Grant, Luther &
Beck, 2014). Using experiential workshops and in vivo
Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
3
coaching, staff were taught the cognitive model, and how to
conceptualize challenging behaviors as obstacles to the
patients recovery goals, rather than problems in them-
selves. Incidents of seclusion and restraints were found
to reduce by more than half, and staff attitudes about
working on an inpatient unit with patients with psychosis
showed significant improvement (Chang et al., 2014).
Building upon the strength of the CBTp model
(Kingdon & Turkington, 2005) and the treatment milieu
approach taken by Beck and colleagues (A. Beck et al.,
2009; Chang et al., 2014), the implementation of CBTp
principles facilitates a coordinated team approach for
an interdisciplinary treatment team. For milieu programs
that have both licensed clinicians and support staff,
an emphasis is placed on specialized formulation-driven
CBTp work taking place during therapy sessions, with
plans then written and shared with all staff so they can
then support and encourage no matter what time of day
or night. In order for this to take place, all staff, regardless
of their training background, are given a working knowl-
edge of specific skills-based strategies such as coping skills
for voices and behavioral interventions for paranoia and
negative symptoms. Licensed clinicians may then take
the lead in developing and sharing the case concep-
tualization, and support staff help extend the clinical
interventions into the milieu. Below, the ACCESS model
offers a road map for implementing this framework in
a therapeutic milieu.
Using the ACCESS Model to Train Line Staff in
CBTp-Informed Interventions
The following vignettes illustrate the implementation
of CBTp-informed interventions across a number of
different settings to provide a flexible, relatable, and
concrete illustration of the ACCESS model (Creed et al.,
2014; Riggs et al., 2012; Stirman et al., 2010). Examples
are drawn from the first authors experiences training
staff in psychosis milieus in a number of public health care
settings: Site Aa partial hospital program in a city-
funded mental health agency, recently transformed to
incorporate the recovery model; Site Ban acute in-
patient psychiatry unit in an urban public hospital setting,
recently transformed to treat early psychosis in 16- to
24-year-olds.
Assess and Adapt
Success in any training initiative can be strongly linked
to staff buy-in, which can be enhanced by helping staff
to anticipate how the training might be relevant to them
(Knowles, 1980) and addressing any concerns they may
have. Using open communication and emphasizing
shared aims can also facilitate engagement with training.
This may be doubly important for mental health workers
in the field of schizophrenia, who may have been working
4 Riggs & Creed
for years with minimal clinical supervision or effective
therapeutic interventions. Cynicism and burnout are
often high, and staff can be keen to show the facilitator
all the ways the new initiative will not work (Mueser &
Noordsy, 2005).
At Site B funding was initiated by behavioral health senior
administration as part of ongoing quality-improvement
initiatives. Planning meetings took place with the medical
director responsible for the unit, the associate director
of nursing and the associate chief of psychiatry. Although
these three administrators were able to serve as local
champions for the training, this planning might ideally
have also included unit level administrators, such as the unit
chief and assistant director of nursing, so that more local-
level preparation was undertaken, particularly as multiple
training initiatives and a culture of rapid change throughout
the hospital were known to have had a long-term impact
on staff.
A kickoff breakfast took place at 8 A.M. on the Friday
directly preceding the start of the workshops, attended
by the associate chief of psychiatry, the facilitator, the
unit chief, and assistant director of nursing. All unit
staff who worked the night or early morning shift were
invited to attend, and those who did so heard first-
hand about the exciting new training initiative. The
breakfast was much enjoyed, but attendance was very
low, in part due to limited advertising. It cannot be
stated enough the importance of the kickoff breakfast.
Providing food and drink in a celebratory atmosphere,
including speakers of importance from both the train-
ing provider and the administration of the organiza-
tion, set the positive tone for the forthcoming initiative
and reward staff in advance for the time and effort they
are going to expend.
At Site A, the lead author had the opportunity for
continued meetings with the program manager and senior
program staff, playing the role of ambassador. As an
outside consultant, she was able to hear about the agency
program, its structure, its strengths and weaknesses, and
gather stakeholder feedback about how the strategies
might best be delivered and targeted. She also attended
the program at several different points throughout the
week, joining groups, community meeting, and drop-in
sessions to assess the current therapeutic milieu, as well
as the content and structure of the program. When the
instructor is already employed as a staff member within
the organization, existing staffing structures, hierarchies,
or competing work demands can interfere and create
challenges with this model.
Engagement at this early stage can also create an
opportunity to assess the staffs initial level of knowledge
of the EBP, as well as their attitudes and expectations.
The training plan may then be adapted to address these
characteristics, and subsequent assessment can evaluate
Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
the impact of training on these individual characteristics
(Proctor et al., 2011).
Convey the Basics
After the initial stage of engaging with the organiza-
tion, the actual training begins. Workshops are provided
to all staff, usually 2 to 3 hours on four occasions split over
4 weeks. If all staff cannot be present in the same
workshop due to logistical reasons in the organization
(e.g., retaining sufficient staffing on a unit, reaching all
staff on all shifts), it is important that each workshop
includes staff from all levels of the program so that new
opportunities for staff sharing and engagement are
facilitated. Inclusion of a local champion in the training
can also greatly increase the likelihood of uptake, so
identification and inclusion of these team members in
training can be key (McCormack et al., 2013). Informa-
tion is presented in the workshops via a mixture of
didactics, videos, role-play, and other exercises designed
to get staff thinking, participating, and learning (Riggs
et al., 2012; Riggs, 2015).
When training staff in CBTp-informed interventions
for the milieu setting, it is preferred that the whole
program be aligned with CBTp principles, which leads
to a more programmatic and team-oriented approach
across disciples, so that each team member functions in
his or her job role but has a common way of interacting
with the individuals receiving services (informed by the
CBTp principles). Ideally, all members of the team re-
ceive a basic understanding of the key concepts of CBTp
as a coordinating framework for care. Staff all learn to
use elements of CBTp (e.g., empathy, rapport building,
and engagement; working within a strongly held belief
system while avoiding collusion; basic strategies for coping
with voices, delusions, thought disorder, and negative
symptoms). In addition, line staff become familiar with
more advanced interventions that may be delivered by
therapists so that they can support and reinforce the use
of new skills in the milieu. For example, staff may learn
about coping cards so that their use may be cued as
needed during daily interactions.
For example, at Site B, training took place over a
2-month period, with workshops scheduled at different
times of the day to ensure attendance of all staff and
make-up sessions in the second month for those who were
unable to complete all four workshops in a row. Four
workshops were provided to each staff member in total, of
2 hours each. As such, the facilitator ran each workshop
three times. All staff on the unit were to be included in
the training, from psychiatric technicians with a high
school diploma, right up to the attending psychiatrists.
Sixty staff were trained, including RNs, licensed creative arts
therapists, activity therapists, peer counsellors, psychiatry
 A Model to Transform Psychosis Milieu Treatment
residents, psychologists, social workers, and staff specialists
in behavioral interventions to deescalate violence, from
all three shifts both day and night. Training was funded
in-house. Staff who worked shift patterns were paid over-
time for remaining 2 hours past the end of their shift or
for coming in early. Nine-to-five staff attended workshops
during this time period and were released from regular
duties during this time. Funding was also provided for
workshop materials, including handouts and binders. As
the instructor was an employee of the hospital, and had
previously worked on a similar inpatient unit, she was
known to some of the staff and was very familiar with all
the different staff roles and the politics of working in the
hospital, which may have facilitated staff buy-in.
Concerning CBTp-informed interventions for the ther-
apeutic milieu, two elements are emphasized during the
workshops to enhance everyday interactions between staff
and individuals being served in the milieu: empathy and
working within a patients delusional belief system (Riggs
et al., 2012). In these brief therapeutic conversations, the
emphasis is on staff providing empathic support to people
with psychosis that does not challenge their beliefs,
but also does not collude. This is a central concept in
CBTp and one that is often misunderstood. Challenging
beliefs head-on makes them stronger. Anecdotally, all
people hold strong beliefs about such issues as religion
and politics, and when an acquaintance with opposing
beliefs attempts to challenge us, we more than likely try
to convince them to the contrary. Not only does this
lead us to reiterate all the reasons we hold our beliefs,
but if the conversation continues, we may even discover
new evidence for our beliefs to support our argument.
Further, we may end the conversation feeling frustrated
or misunderstood. None of these outcomes are desirable
in engaging a person around their beliefs. Many of us
also have experience with working with people with
psychosis and may have tried to disprove a belief that was
obviously not true, to little effect (the patient who believes
they are pregnant or HIV positive in the face of repeated
negative blood tests, for example). In CBTp, thoughts
are not challenged, and may only be caught, checked,
and changed if they are found to be inaccurate or un-
helpful (Granholm, McQuaid, Auslander & McClure, 2004)
much later in therapy.
These concepts are taught to staff during the workshop
phase of the training using particular exercises and role-
plays (Riggs et al., 2012). In particular, this workshop
delivery leans heavily on the work of Hazel Nelsons (2005)
concept of working within the delusional belief system,
as well as utilizing an exercise for increasing empathy,
first put forward by McLeod, Deane, and Hogbin (2002).
The first author also uses video clips to help line staff relate
to the experiences of the individuals receiving services.
For example, clips from the movie Lars and the Real Girl
Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
5
(Aubrey & Gillespie, 2007) illustrate beautifully how and
why we work within a delusional belief system, and how
the delusion also often holds specific meaning for the
person in question. For those unfamiliar with this movie, a
man shows up on his brother and sister-in-laws doorstep
accompanied by a slightly shocking delusion. He has a
life-sized doll that he believes is alive, and with whom he
has fallen in love. The brother and his wife are distraught
they catastrophize and blame themselves. However, they
are able to take the young man to the town internist who, in
her wisdom, points out that the delusion must be functional
or meet some need for the man, even if they dont yet
know how. The internist suggests that they must therefore
go with it (i.e., work within the delusional belief system).
The family enlists the support of the town in this en-
deavor, with some initial resistance. Ultimately, the function
presents itself and the delusion resolves. In a related but
real-life example, Eleanor Longdon, a British clinical psy-
chologist and voice hearer, speaking about her experiences
with the behavioral health system in the U.K. (Longdon,
2011), offers a wonderful example of how recovery from
schizophrenia is possible to a much higher level than
people think. Dr. Longdons video also provides firsthand
information about what it feels like to be treated by a
regular mental health system, which can help line staff
to better understand how their daily interactions can have
a positive or negative impact on people with psychosis.
Consult
Following the intensive workshops, the consultation
phase begins. During this time, the instructor visits the
program for hourly case consultation discussions, in which
staff bring real-life examples from their program, and
these are discussed in an attempt to formulate them using
the CBT for psychosis model. These are scheduled as
frequently as the funding agency will allow, ideally offering
contact at least once per week for each staff member.
The consultation phase is where change really begins
to happen (Miller, Yahne, Moyers, Pirritano, & Martinez,
2004; Sholomskas et al., 2005). At Site B the workshops
were followed-up with a 1-year consultation phase, during
which the facilitator attended the unit for a 1-hour weekly
case consultation meeting. The timing of this meeting
was also rotated so that staff from the two daytime shifts
could attend. (Unfortunately, due to logistical reasons,
it was not possible for a case consultation meeting to be
scheduled for the night shift.) To begin with, the weekly
case consultations were poorly attended, particularly by
nursing staff. Despite partnership in planning the timing
of the sessions across all disciplines, it was typical for
clinical staff to be available to meet, while nursing staff
were already assigned other important duties at that time.
However, with repeated emails the assistant director of
6 Riggs & Creed
nursing on the unit began to schedule for nursing staff
to arrive an hour early for their shift or to stay late and
attendance rocketed. It is really important, as with the
workshops, to ensure that all disciplines are represented
at these meetings with the emphasis on sharing and
learning from each other. Generally, these meetings
took the form of presenting 1 or 2 patients from unit,
formulating their psychotic experiences from a CBTp
perspective, and sharing ideas about interventions. The
facilitator attempted to model a collaborative, Socratic
questioning approach throughout.
At Site A, weekly consultation sessions were provided
over a 6-month period. Consultation took place for an
hour once a week, with all staff mandated to attend. Staff
presented case examples for feedback and troubleshoot-
ing. The instructor then presented a review topic with
an experiential exercise, followed by new intervention
setting and summary. Topics initially flowed from didactic
workshops, but quickly became based on requests from
staff for troubleshooting and additional information.
Initially a role-play between pairs of staff members was
always included. However, because staff had been
disengaging during the role-play, this was revised to
watching the instructor role-play with a member of staff,
and team-by-team case presentation with whole group
discussion. In addition, the instructor attended each
teams meeting on a three weekly rotation, at which staff
presented a particular participant they were struggling to
work with. A CBTp-based formulation was constructed,
and interventions were suggested. Finally, the instructor
was on-site informally 1 hour a week, interacting with
consumers, modeling good practice interventions, and
able to answer additional staff questions.
Staff are also encouraged to practice coaching indi-
viduals in specific strategies to help diminish voices, delu-
sions, and negative symptoms. For example, staff may
offer individuals the point-look-name strategy (Riggs,
2015) for reducing voices. In this strategy, a psychiatric
technician (tech) on an inpatient unit may observe that
a young man looks distracted and upset, and based on
her knowledge of the young man, hypothesize that he
may be reacting to an auditory hallucination he fre-
quently experiences. After inquiring about the young
mans experience, she reminds him of his past successes
with the look-point-name strategy to shift his focus from
the critical voice he is experiencing to the environment
around him. The tech asks the young man if he is willing
to find out whether he might find that strategy useful
again currently (empathic, collaborative). With guidance
as needed, the young man begins to look around the
room, point at specific objects, and name what he is
pointing out, engaging several systems in his brain and
refocusing away from the auditory hallucinations. This
strategy is in contrast to the tech engaging around the
Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
voices, such as arguing about the voices (which could lead
the young man to defend himself and his experience),
colluding with the hallucination (which may become
further evidence to him that the voices have power or
are important), trying to ignore the voices (which is
another way of paying attention to them, often increasing
his experience of them, as well as his sense that they are
uncontrollable), and so on. By focusing on the environ-
ment rather than internally, the volume knob on the
voices is turned down. In an elegant intervention, the
tech may then help the young man pay attention to the
meaning he makes from this experience. If the voices
recede when he focuses elsewhere, what does that tell
him about how powerful or uncontrollable the voices are?
(See Riggs, 2015, for more details of the CBT model as
applied to these symptoms and more information about
this and other strategies.)
Consultation may also be particularly valuable in sup-
porting the coordinated efforts among treatment team
members. For example, a psychologist may work with a
woman to identify beliefs she holds about herself, based
on past experiences, including Im broken, or Im a
failure. The psychologist may then work with the woman
to identify and engage in new mastery between sessions
to build evidence against those beliefs. At a day program,
for example, the woman may offer to teach other inter-
ested individuals to sew, creating opportunities for her
to experience herself as capable and successful. Support
staff can then watch for these and other moments, and
help draw her attention to the successes she might other-
wise miss or discount. Consultation may be particularly
helpful in facilitating communication among disciplines
to support and extend these experiences. Special care
should be paid to communication across shifts, as cross-
shift communication may be observed to be a particular
challenge. Integration of key information into shift-change
updates, treatment team meetings, and documentation
may be particularly effective, but effective approaches will
need to be adapted to each setting.
Evaluate Work Samples
When implementing any EBP, evaluation of work sam-
ples allows direct measurement of the extent to which
trainees have learned to deliver the intervention as the
treatment developers intended (Proctor et al., 2011).
Fidelity in standard CBT is often typically measured using
the Cognitive Therapy Rating Scale (CTRS; Young &
Beck, 1980) to rate audio- or video-taped sessions, and
many modified versions exist for training individual cli-
nicians to do full CBTp: Cognitive Therapy Scale for
Psychosis (Haddock et al., 2001); Cognitive Therapy in
Psychosis Adherence Scale (Rollinson et al., 2008); Cogni-
tive Therapy Scale Revised for Psychosis (Munro-Clarke,
 A Model to Transform Psychosis Milieu Treatment
2015). However, when training staff in therapeutic milieu
enhancement, recording the daily interactions that con-
stitute most of the interventions is often not feasible.
Instead, work may be evaluated indirectly during weekly
consultation discussion, through evaluation of staff skills
during role-plays, or through in vivo observation of staff
in the milieu. Direct observation of skills in the treatment
milieu may offer the best of these options, as observation
provides the most accurate data about staff skills and
feedback can be provided instantaneously. However, staff
may find the observation distracting or uncomfortable,
so subtlety during the observation may be particularly
important.
Several measures of integration of CBT into the milieu
are under development. An observational measure of the
integration of a goal-oriented CBT into the treatment
milieu is currently being piloted in a large-scale imple-
mentation of CBT in community mental health (Creed
et al., 2015). In addition, Sivec and colleagues (Sivec,
2015) have been developing a modified checklist version
of the CTRS to be used to measure the fidelity of case
workers being taught to use CBTp-informed interventions
in Assertive Community Treatment team settings. When
available, this may be usefully applied to milieu settings
as well.
At Site A the instructor was able to attend the program
every Friday morning, at least an hour of which was
dedicated to spending time solely in the milieu, interact-
ing with consumers, modeling good practice, observing
staff interactions, and giving live feedback and shaping. As
the 6-month consultation progressed, it was notable that
modeling and live feedback was required, not only praise
and reinforcement of good practice.
Sustain
Many different factors may facilitate the implementa-
tion of an EBP in the earlier stages of implementation,
but the influence of those factors may change over time,
potentially limiting the long-term impact of implementa-
tion (Massatti, Sweeney, Panzano, & Roth, 2008; Scheirer,
1990; Seffrin, Panzano, & Roth, 2008). Research targeting
the best approaches to improve or sustain EBPs is still
in its very early stages, and the ideal strategies remain
pressing areas of research (Proctor et al., 2015). Among
the emerging literature, much has focused on national or
statewide initiatives, with little guidance for local mental
health systems or individual behavioral health organiza-
tions that are implementing EBPs more independently
(Stirman et al., 2015).
Turnover is a particularly salient issue in community
mental health, typically ranging from 30% to 60%
annually (Mor Barak, Nissley, & Levin, 2001). When
staff are trained and then lost to turnover, those resources
Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
7
may be lost to the milieu. For example, within the first 6
months of the consultation phase of training at Site B,
approximately 50% of the staff who had attended the
initial workshops had taken new jobs outside of the
hospital or been floated or transferred to a different unit
or program within the hospital. When the resources are
available, didactics may be offered to new staff members
after the end of the consultation phase, helping orient
new staff, and inciting fresh enthusiasm in the whole
team, but access to ongoing training may not always
be possible for organizations. The milieu staff offer an
excellent source of ideas and information for feasible
sustainability strategies within their system, with direct
knowledge of the resources and barriers of their context.
CBTp-trained milieu staff have suggested and enacted
strategies for sustaining the CBTp culture on their units,
including access to written materials and information
such as books or papers kept in a centrally available
library (including both established resources, and re-
sources developed and updated by the team), video
training material for new staff and for caregivers, and
access to instructors for consultation on a case-by-case
basis. The use of web-based training has also evidenced
great utility in replenishing trained staff after turnover
(Creed et al., 2014), allowing new staff to access the
necessary foundational knowledge as they enter the
organization. Their growing skills are then supported by
the daily flow of the CBT milieu.
At Site A the instructor provided an additional work-
shop after the end of the 6-month consultation period to
bring new members of staff up to speed with the material
and initiative. This was largely driven by staff request
as they had noticed how important the initiative was to
the program and wanted to get up to speed as fast as
possible. In addition, each of the three staff teams was
led by a masters-level clinician who had been trained in
a previous initiative in individual CBT and who became
important local champions for CBTp-informed milieu
interventions and greatly supported both their teams
and the program, with long-term sustainability of the
interventions. One of these three undertook additional
training in group CBT interventions for voices and para-
noia, another undertook further supervision for her
individual client work with patients with psychosis using
the CBTp model, and the third was promoted to clinical
lead of the program and continued to champion CBTp-
informed interventions from this level. At Site B, because
the instructor was an employee of the hospital, sustain-
ability was conceptualized within the framework of an
ongoing in-house expert. This was further reinforced by
hiring a new psychologist to the unit who had also had
previous training and experience in using CBTp. In
both instances, long-term investment in the infrastruc-
ture by management (i.e., support for additional training,
8 Riggs & Creed
establishment of local champions, hiring the instructor as
in-house staff) helped to create stability and demonstrated
administrator commitment to CBTp. The availability of
in-house resources, in turn, created an opportunity for
the penetration of CBTp to expand.
Study Outcomes
The ACCESS model highlights the importance of
studying outcomes in collaboration with the agency,
but this may be difficult to do in a formal or controlled
fashion (Seiber, 2008). Outcomes can be difficult to
define with agencies, especially when interventions are
not targeted to specific individuals, but rather the milieu
as a whole. Standardized measures may be administered
to staff to assess changes in attitudes, burnout, or other
characteristics, but the time and effort required for
data collection and analysis may be beyond the scope
of smaller or less-resourced organizations. On a related
note, not all organizations are equipped to support the
Institutional Review Board applications that are required
to conduct research, so data collection may be limited to
routine program evaluation.
Although collection of data can be a very labor-
intensive task, with those administering the question-
naires often required to provide support to individuals
as they complete the questions, checking for legibility and
incomplete data, and reminding staff of the assurance
on confidentiality of the data, the labor leads to objective
information about the impact of the implementation.
Questionnaires to consider include: The Ward Atmo-
sphere Scale (WAS-R; Moos, 1974), The Staff Attitudes
Survey (McLeod et al., 2002), The Community Oriented
Programs Environment Scales (COPES; Moos, 1972),
The Community Assessment of Psychic Experiences
scale (CAPE; Stefanis et al., 2002), the View of the
Therapeutic Environment (VOTE; Laker et al., 2012),
and the Competency Assessment Inventory (CAI; Chinman
et al., 2003). Data being collected as part of standard
care may also be accessed (with appropriate permission)
to assess the impact of implementation on events on the
unit. For example, rates of seclusion, physical restraint,
critical incidents, or intermuscular medication use may be
tracked to determine whether any changes are evidenced.
At Site B, as part of IRB exempt program evaluation,
staff completed the WAS-R prior to training and again at
6 months into the consultation phase as a measure of
the milieu (Riggs & Nikolov, submitted). In addition,
data were collected routinely on the unit on rates of
aggression, restraint, and emergency medication admin-
istration and analyzed for the period 6 months prior to
and 6 months after the training. A trend towards im-
provement in the milieu was found, along with reduction
of both episodes of aggression and restraints.
Please cite this article as: Riggs & Creed, A Model to Transform Psychosis Milieu Treatment Using CBT-Informed Interventions, Cognitive and
Behavioral Practice (2016), http://dx.doi.org/10.1016/j.cbpra.2016.08.001
Next Steps
CBTp can effectively reduce the distress experienced
due to positive and negative symptoms, and can improve
the quality of a persons life (Wykes, Steel, Everitt, &
Tarrier, 2008). A programmatic approach to CBTp offers
a vehicle for transforming the therapeutic milieu within
which many people with psychosis are supported, and
may increase access to the evidence-based approach. As
an organizing principle, delivery may be conceptualized
according to three levels, or tiers. As an intensive,
formulation-driven therapy, full CBTp can be provided
on a one-to-one weekly basis by masters-level clinicians or
above who have received lengthy and specialist training,
sometimes referred to as Tier 3. Such trained clinicians,
with supervision, could be able to work with anyone with
psychosis, regardless of diagnosis or symptom presenta-
tion. However, at Tier 2, clinical staff can be taught to
provide targeted CBT-pspecific CBTp interventions
targeting a specified mechanism or symptom (such as
command hallucinations or sleep for people experienc-
ing paranoia) and that typically follow an evidence-based
manual, but for which both length of training and number
of treatment sessions is shorter. At Tier 1, line staff within
milieu settings may use CBTp-informed interventions,
such as increased empathy, and understanding of how
to work within a persons delusional belief system, as well
as specific skills-based coping strategies, to improve out-
comes for people with psychosis.
CBTp is finally getting some buzz in the U.S. now
among clinicians, service providers, and mental health
agencies, and many more people are being trained.
However, the need for caution remains. Evidence-based
practices need to be implemented in a way that is also
evidence based, increasing the likelihood of changing
staff practices. Those investing in training need to know
that their money is being usefully spent, and to know
what kinds of changes they can expect in return. This
model suggests one way in which Tier 1 CBTp can be
implemented according to the research base, to have a
major impact on not just the lives of people with psychosis,
and on those who are involved in their care, but also
potentially their families, friends, and society as a whole.
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The authors would like to acknowledge the contribution of Shannon
Wiltsey-Stirman, Ph.D., for her ongoing mentorship and expertise in
training and dissemination. They would also like to thank the Beck
Community Initiative, the Philadelphia Department of Behavioral
Health and Intellectual disAbilities, and New York City Health +
Hospitals who supported this work. Finally, thank you to JCR for the
grammatical expertise.
Address correspondence to Sally E. Riggs, DClinPsy, NYC
CBTp, 142 Joralemon Street, Suite 5F, Brooklyn, NY 11201; e-
mail: sallyeriggs@gmail.com.
Received: July 28, 2015
Accepted: August 9, 2016
Available online xxxx