Transcript The Challenge of a psychological therapies service in an

The Challenge
of a psychological therapies
service in an acute in-patient
unit.
Isabel Clarke and Hannah Wilson
Clinical Psychologists from AMH
Woodhaven.
The challenge of therapy delivery
Variable and unpredictable admission
times
Mixed diagnoses
Time of crisis
Risk factors
The challenge of working with the system
Combining psychological with medical
approaches
Developing therapeutic skills across the
board
Having an impact on milieu and morale
The challenge of evaluating the work.
Finding a way to measure the impact of the
psychological therapy; routine
interventions also contribute to symptom
change, therefore before and after
symptom measurement is not indicative of
effectiveness.
The Challenge of Therapy Delivery.
 The key features of the Woodhaven therapeutic
approach are as follows:
 Simple formulation based on relationship to emotion,
informed by the ICS split between the emotional and
logical systems. (Interacting Cognitive Subsystems: see
Teasdale & Barnard 1993)
 A “Third Wave” Cognitive therapy – focus on intervening
between thought and feeling rather than altering thought
to effect feeling (see Hayes et al. 1999)
 Management of arousal (breathing control), and
mindfulness training to facilitate intervention in the
cognitive/emotional process.
Key features cont.
 Techniques of meeting, expressing and letting
go of emotion as opposed to the previous
avoidance.
 This draws on Linehan's (1993) approach and
has similarities to Emotion Focused Therapy
(Greenberg 2002).
 Practical discussion of lifestyle management to
ensure the continuation of a better adjustment.
 All these features are designed to enable
someone to take control of their own recovery –
in sympathy with the Recovery Approach (e.g.
Repper & Perkins, 2003).
Typical formulation
PAST ABUSE
LOSSES
PARTNER LEAVING
Nightmares: can’t sleep
Cut self
Attempt suicide
FEAR
RAGE
SADNESS
More difficult to cope
Friends and family alarmed.
Could lose custody of
children.
Avoid going out and seeing
people
Feel worse
More time to brood
WAYS FORWARD
Don’t let the feelings be in control: YOU ARE IN
CHARGE
Do things despite the feeling
Breathing and mindfulness to get back to the present
Use the energy of the anger positively
Working with the Institution.
 Service users in crisis have a need to ‘make
sense’.
 Staff also need to ‘make sense’.
 Reflection in the face of crisis and risk needs the
skills of psychological thinking. The
Psychological Therapies Service can support,
develop and inform this psychological thinking.
 In Woodhaven, this is achieved by:
 Joint psychological assessment with key-worker.
 Supervision of joint psychological work.
Further working with the Institution
 Weekly Reflective Practice Groups for each
ward, for the nursing staff, facilitated by a
psychologist.
 Co-facilitated, multi-disciplinary group work with
a psychological focus.
 Psychology-led training for staff group on
developing strengths based care planning for
the most challenging clients.
 Training has lead to request for regular multidisciplinary care planning meetings (to be
implemented)
Evaluation of the Individual
Therapy Service.
This was set up by Caroline Durrant
(Assistant Psychologist), and conducted
while she was with us (between
September 2004 and March 2005). The
period measured intensively was short
because of the short duration of this
support. Abigail Tolland (who worked
briefly with us as an honorary assistant
psychologist), assisted with the analysis of
the data.
Principles behind design of the
evaluation.
 Designed to measure the intervention described
above.
 Measurement of symptom change not useful for
evaluation because of concurrent interventions
(medication etc.).
 Self efficacy and management of emotions are
the aims of the intervention, hence they are
evaluated.
 Measurement of individual Goal achievement.
Measures
1. CORE - to measure level of psychopathology rather
than change.
2. Mental Health Confidence Scale (MHCS)
(Carpinello, Knight, Markowitz & Pease, 2000)
The MHCS measures self-efficacy in relation to mental
health. It is a sixteen item scale that measures three
factors: confidence in the development of hope,
confidence in the ability to manage symptoms and
emotions, and confidence in the ability to advocate for
one’s needs and rights. For each item scores are
indicated on a Likert scale ranging from 1 = not confident
to 6 = very confident. Total scores are gained by the
sum of the items. It has high construct validity and low
error variance making it a reliable measure.
Measures cont.
3. Locus of Control of Behaviour Scale (LCB)
(Craig, Franklin & Andrews, 1984)
The LCB scale is a seventeen item scale focusing
on perceived control over mental health
problems. Each item is rated using a 6 point
Likert scale where 0 = strongly disagree and 5 =
strongly agree. The scale is a reliable and valid
measure with clinical samples.
4.Goal Setting: Visual-analogue, ideographic,
measure of individual goals.
Measures cont.
5. Living with Emotions
The Living with Emotions measure was designed for this
research. It consisted of three questions looking at
confidence in coping with emotions. Each question is
scored on a Likert scale to allow for accurate before and
after comparison. The scales range from 0 = not at all
confident to 10 = extremely confident. Total scores are
calculated using the sum of the items. Beneath the
scales is a fourth closed question asking about efficacy
of techniques for coping and an open question
concerning which techniques are most useful.
Carpinello, S.E., Knight, E.L., Markowitz, F.E. & Pease, E.L.
(2000) The development of the mental health confidence
scale: A measure of self-efficacy in individuals
diagnosed with mental disorders. Psychiatric
Rehabilitation Journal 23 pp236 – 243
Craig, A.R., Franklin, J.A. & Andrews, G. (1984) A scale to
measure locus of control of behaviour. British Journal of
Medical Psychology 57 pp173-180
Results
 Pre and post therapy scores suggest that service
users felt:
 more able to cope with their mental health difficulties
 had a greater internal sense of control
 felt more confident in dealing with their emotions
 felt more confident in employing strategies to deal
with strong emotions.
SUMMARY AND CONCLUSIONS
1. Psychological services can contribute to
developing a therapeutic milieu in an in-patient
acute setting in a number of ways:
staff support and training
reflective practice,
on-going supervision,
group and individual therapy
2. Service users report increased confidence and
coping after very brief psychological therapy
Directions for the Future
1. Ongoing evaluation of the brief individual
therapy.
2. Working with new teams: The same model is
being extended to Crisis Resolution Home
Treatment and Assertive Outreach Teams and
will be evaluated. This will facilitate smoother
psychological working across discharge.
3. Evaluation of the impact of these approaches
upon on re-admission rates over time.
Directions for the Future cont.
4. Continuing development of the
multidisciplinary DBT programme, its
evaluation and application across
diagnoses.
5. Evaluate the impact of psychology led
reflective practice on nursing practice, staff
morale, ward atmosphere etc.
6. Evaluate the impact of psychology led
training on ward practice.
Development of a DBT in-patient
service
 A psychology led, multi-disciplinary team at
Woodhaven are trained in DBT. The team are
implementing an adapted programme for the
unit which includes:
 1:1 weekly therapy following the DBT model
 Individual skills training
 6 week Emotional Coping Skills (ECS) group
 Chain analysis after incidents of self harm
 Risk management advice
 Staff training and education
 Consult team for support and supervision
Evaluation of DBT service.
Evaluation of the programme includes the
Mental Health Confidence Scale (MHCS),
Work and Social Adjustment
Questionnaire and Living with Emotions
(LWE) questionnaire. Outcome data for
the first year of the ESC group are
positive:
Contact Details and References
• [email protected]
• [email protected]
• Durrant, C., Clarke, I., Tolland, A. & Wilson, H. Designing
a CBT Service for an Acute In-patient Setting:A pilot
evaluation study. Accepted subject to amendment by
Clinical Psychology and Psychotherapy.
• Forthcoming book: Cognitive Behaviour Therapy for
Acute Psychiatric Inpatient Units; working with clients,
staff and the milieu. Edited by Isabel Clarke & Hannah
Wilson. Routledge.
• Plans for a Symposium on CBT for inpatient units at the
forthcoming BABCP conferences.
• Isabel’s website:
www.scispirit.com/Psychosis_Spirituality/