Recruiting and retaining therapists

The initial protocol included a feasibility RCT to compare CT-SAD-A with a CBT programme that can be applied across different types of anxiety disorders and is commonly used in child and adolescent mental health settings (‘The C.A.T. Project’).⁴⁵ To ensure that we had enough trained therapists to deliver treatment within each arm (n = 3), we set out to identify 10–12 therapists to allow for a potential loss of trained therapists. In line with our plans, we initially identified 12 CAMHS therapists within the participating services who met our study inclusion criteria and who were willing to take part. Within the early stages of the study, five therapists withdrew from the project (Figures 1 and 2) after being allocated to training but prior to attending the workshop, the ‘not included in training’ box. This meant that we had to engage therapists from additional CAMHS teams within the participating NHS trusts and ensure that there would be therapist representation across both study arms in each of the five teams (as therapists were not able to work across teams). In total, 20 therapists were recruited to the study and 19 were allocated to treatment arms. In total, 10 of those therapists withdrew from the study (including the five therapists mentioned above) and one went on maternity leave towards the end of the training phase. In addition, one therapist resigned from her NHS role but agreed to continue to participate in the study. Figures 1 and 2 show therapist recruitment and retention to the study, and also reasons for therapist withdrawal. The final distribution of therapists across clinical teams is shown in Table 2, with their core professional training detailed in Table 3. As can be seen, in many locations there was only one therapist trained in each of the two therapies, which left the study extremely vulnerable to any further therapist loss.

FIGURE 1

Therapist recruitment and retention to the study (Berkshire Healthcare NHS Foundation Trust). BHFT, Berkshire Healthcare NHS Foundation Trust.

FIGURE 2

Therapist recruitment and retention to the study (Oxford Health NHS Foundation Trust). Ox Health, Oxford Health NHS Foundation Trust.

TABLE 2

Allocation of therapists by team at each location across treatment arms and NHS trusts

TABLE 3

Core professional training of therapists available for study

Owing to high service demand and staff vacancies in all participating CAMHS teams, all service managers placed restrictions on the amount of time (and, hence, the number of trial cases) that the participating therapists could spend on the study (meaning only one or two patient contacts per week were possible). Although we secured excess treatment costs (ETC) to reimburse teams for the additional therapist time taken by the trial, this was of limited help to them, as they all had unfilled vacancies and so there was no scope to backfill existing staff (particularly as ETCs are paid in arrears). As a result, with the therapists available, we would have been able to recruit a maximum of n = 26 (13 per arm), rather than n = 48 as initially planned to test the feasibility of a RCT. This was likely to be an optimistic figure based on therapists being able to seamlessly pick up new trial patients immediately after completing therapy with a previous patient. Although there was one further therapist in Berkshire Healthcare NHS Foundation Trust (BHFT) who was available and willing to take part in the study, none of the sites across Oxford Health NHS Foundation Trust (OxHealth) was able to provide additional therapists due to the high demand on services and there being a number of unfilled vacancies/staff on maternity leave across all sites. Given this, it was not possible to secure sufficient CAMHS therapist time to be able to run the feasibility trial within the participating NHS trusts.

Recruiting and retaining young people with social anxiety disorder

We found that some of the participating CAMHS teams identified few young people with a primary SAD, as activity was increasingly dominated by risk management. Given this, some of the participating sites struggled to identify suitable participants for the trial, recruitment of training cases was slow, and therapists were not always able to work at their full allocated capacity. For example, between July and December 2017, only one training case was recruited on a site in which there were three therapists participating in the study. To overcome this, we had to reach out beyond the services to identify suitable training cases (e.g. to neighbouring services and to local schools’ hubs). However, this created challenges for services who were already struggling to meet the existing demand.

Figures 3 and 4 show patient participant recruitment and retention to the study. Of those young people identified as potentially eligible for the study, less than one-quarter ended up participating in the training series for a broad range of reasons. Notably, when potential participants were assessed and confirmed as eligible for the study, uptake and retention was high. In total, 26 out of 35 (74%) young people who were contacted by the research team participated in the study, 12 out of 14 (86%) were retained throughout treatment and 11 of these 12 (92%) completed the follow-up assessment.

FIGURE 3

Patient recruitment and retention to the CT-SAD-A training phase (Berkshire Healthcare NHS Foundation Trust). a, Training was postponed from September 2016 to June 2017 while the primary supervisor was on maternity leave.

FIGURE 4

Patient recruitment and retention to the CT-SAD-A training phase (Oxford Health NHS Foundation Trust). a, Training was postponed from September 2016 to June 2017 while the primary supervisor was on maternity leave.

Action taken

In response to the difficulties that we experienced with recruiting and retaining CAMHS therapists and identifying eligible young people within CAMHS, we considered extending recruitment to other NHS trusts. However, after extensive consultation with representatives from a range of CAMHS teams, it was clear that this was not going to be possible, because (1) a substantial increase in costs would be required to be able to conduct the required diagnostic assessments across a wider geographical area and/or (2) other NHS CAMHS teams reported having similar problems with staffing (i.e. unfilled posts and a rapid turnover of staff) and caseloads that were increasingly dominated by high levels of risk. As a result of the difficulties with therapist retention and participant identification, we concluded that the feasibility question that we set out to address had been answered and that the proposed RCT would not be feasible in the current CAMHS context. Given this, we felt that it was not a responsible use of NIHR funds to proceed to the RCT phase of the study. To maximise the learning from the work and investment that had taken place, we proposed the following next steps:

• We would complete CT-SAD-A treatment and post-treatment assessments with all the training cases to report on an extended case series of application of the novel treatment (CT-SAD-A) in routine CAMHS (including costs of treatment delivery).
• We would move forward qualitative work that had been planned alongside the RCT phase of the original proposal to learn about young people and parents’ experiences of receiving this novel treatment within a CAMHS setting to inform future work about how best to deliver specialist psychological treatments in CAMHS.
• We would extend the proposed qualitative work to include therapists and service managers to learn from their experiences of (1) delivering CT-SAD-A within routine CAMHS and (2) participating in psychological therapies research in routine CAMHS, to learn both about the application of specialist psychological treatments in CAMHS and about what needs to happen to enable CAMHS to participate in research.

This proposal was agreed by the SSC and the NIHR HTA programme. The following chapters report on the outcomes of the revised programme of work.