Transcript The Challenge of a psychological therapies service in an

CBT for Inpatient and Crisis
Settings:
A Newly Developed CBT Approach to Enable
the Individual to Make Sense Of Crisis, and
Enhance the Milieu
Isabel Clarke and Hannah Wilson
Clinical Psychologists
AMH Woodhaven.
The case against acute phase
individual CBT
• Admissions are too short and
unpredictable to deliver NICE guideline
adherent, diagnosis linked, treatments
• People too disturbed and fragile; for
instance, for exploring trauma history –
might destabilise
• Better wait to refer to Psychological
Therapies on discharge
The Case for Acute phase CBT
• Crisis is the time when people most need to make sense
of what is happening to them
• - To make sense in a way that leads to the individual
taking control – a way out of the revolving door.
• Crisis as a window of opportunity – ‘the turning point’ in
Recovery terms.
• Unbearable emotion as the simple heart of complex
problems – identify ways forward that the team can
deliver (nurse led group work, practical help from
community teams etc.)
• A basis for spreading psychological thinking throughout
the staff group.
A CBT Approach for Inpatient and
Crisis Work
Cross diagnostic
Suitable for working with high states of arousal –
identifies feeling awful inside and the individual’s
relationship to this feeling as the problem.
Effective over one, two or three sessions
(evaluated – see Durrant et al).
Introduces approaches to change that can be
supported by staff on the ward, and carried on
by CPN etc. in the community after discharge.
“Third Wave” – term coined by Hayes
(Acceptance & Commitment Therapy)
• Kabat-Zinn. Applied mindfulness to stress
and pain.
• Segal, Teasdale & Williams. Mindfulness
Based Cognitive Therapy (relapse in
depression.)
• Linehan. Dialectical Behaviour Therapy
(BPD)
• Chadwick. Mindfulness groups for voices.
• Hayes
“Third Wave” Cognitive Therapies
• Developments in CBT as it tackles
personality disorder, psychosis etc.
• Therapeutic relationship important
• Past history is significant
• Change lies not so much in altering
thought to alter feeling, but in altering the
person’s relationship to both thought and
feeling
• Mindfulness is a key component.
Applying CBT to Severe Mental
Health Problems.
• Therapy is about healing the relationship
between an individual and themselves.
• Relationship is governed by emotion
• CBT works on emotion by seeking to alter
thought, behaviour or state of arousal
• Where problems are rooted in early trauma etc.
patterns are set up that are resistant to revision
• The cool reflection needed is hard to achieve
LEVELS OF PROCESSING – A THEORETICAL
JUNGLE!
• The cool reflection problem leads to the recognition
of different types or levels of processing within CBT
e.g.s of theories of this.
• Ellis: Inference and Evaluation
– Hot and Cold cognition
• Power & Dalgleish. SPAARS (theory of emotion).
• Mark Williams: overgeneral autobiographical
memory.
• Metacognition.
• Wells & Mathews. S-REF
– . 'Vulnerability to psychological dysfunction is associated with a
cognitive-attentional syndrome characterised by heightened selffocussed attention, attentional bias,ruminative processing and
activation of dysfunctional beliefs. ...mediated by executive
processes that are directed by the patient's beliefs'.
• Brewin’s VAMS and SAMS (just memory).
• Ehlers & Clark (following Roediger): conceptual
v.data driven processing.
Features the theories have in common.
• There is one direct, sensory driven, type
of processing and a more elaborate and
conceptual one.
• The same distinction can be found in
the memory.
• Direct processing is emotional and
characteristed by high arousal.
• This is the one that causes problems –
e.g. flashbacks in PTSD.
Features of Emotion Driven Processing
• Emotion regulates relationship – both with yourself and
others
• It mobilises the body for action
• That physical mobilisation gives the emotion its punch
• Where physical arousal is prolonged it is unpleasant –
motivates people to avoid emotion
• Time is collapsed in Emotion driven processing – past
threat is added to current threat (cf. Brewin’s PTSD
research)
• Role of past trauma in psychosis and PD is now being
properly recognised.
Ideas to think about
• Symptoms are just different ways of escaping
from or avoiding unpleasant emotions – what
examples can you find?
• In the light of this way of looking at things,
what should be the main goals of therapy?
• To meet those goals, where does CBT need
to direct its efforts?
• What therapeutic methods are likely to be
useful?
• What becomes less important?
Linehan’s STATES OF MIND (from Dialectical
Behaviour Therapy) – Maps onto Interacting Cognitive Subsystems
EMOTION
REASONABLE
WISE
MIND
(Propositional
Subsystem)
MIND
MIND
(Implicational
subsystem)
IN THE PRESENT
IN CONTROL
The ‘horrible feeling’
• Human beings need to feel physically safe
and OK about themselves
• Emotion Mind/Implicational Subsystem
produces a sense of threat when those
conditions are not met
• Emotion Mind/Implicational memory
presents past events as present (trauma)
• People develop ingenious ways of
avoiding facing the sense of threat
WAYS OF COPING WITH FEELINGS
WHERE THREAT TO SELF IS TOO GREAT
•
•
•
•
•
•
Giving in - signalling submission (depression)
Constant anxiety, worry and hypervigilance
Anger - attribute elsewhere.
Displacing anxiety - OCD, eating disorder
Drink, drugs, etc.
Dissociation - flipping between different
experiences of the self
• Cutting out reasonable mind appraisal –
psychosis
Linehan’s STATES OF MIND (from Dialectical
Behaviour Therapy) – Maps onto Interacting Cognitive Subsystems
EMOTION
REASONABLE
WISE
MIND
(Propositional
Subsystem)
MIND
MIND
(Implicational
subsystem)
IN THE PRESENT
IN CONTROL
Figure 1. Typical Formulation
PAST ABUSE
LOSSES
NIGHTMARES
CAN’T SLEEP
MORE DIFFICULT
TO COPE
PARTNER
LEAVING
CUT SELF
ATTEMPT SUICIDE
FRIENDS & FAMILY
ALARMED. COULD LOSE
CUSTODY OF CHILDREN
FEEL WORSE
FEAR
RAGE
SADNESS
AVOID GOING
OUT:SEEING
PEOPLE
MORE TIME TO
BROOD
Psychosis formulation
The past
Being in crowds, busy places
Intrusive thoughts
Fear
Sense of threat
Hears voices
This means I’m bad and
others want to hurt me
This also means I’m bad and
others want to hurt me
Tense, sweaty,
heart races
Withdraw, hide
away
Or Fight,
becomes
aggressive
Escapes from thoughts
By slipping into unshared world
The Individual Therapy Approach
 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.
The Individual Therapy Approach 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).
Providing a cognitive science
based theoretical context.
•
•
•
•
•
Interacting Cognitive Subsystems
Evolutionary approaches - Gilbert etc.
Attachment theory - Bowlby etc.
Cognitive Analytic Therapy.
Current approaches to CBT for
personality disorders:
• Schema focussed approaches
• Dialectical Behaviour Therapy (Linehan)
• ACT.
Interacting Cognitive Subsystems.
Body
State
subsystem
Implicational
subsystem
Implicational
Memory
Auditory
ss.
Visual
ss.
Propositional subsystem
Propositional
Memory
Verbal
ss.
The Propositional Subsystem
• Verbal coding.
• Manages logical thought - “cool
cognition”
• Verbally coded memory store integral to
the subsystem.
• Communicates directly only with the
other language subsystems.
• Intercommunication between it and the
implicational subsystem = “Central
Engine of Cognition.”
Implicational Subsystem
• Coded in all modalities - memory and
current processing
• Concerned with meaning and
significance
• Information about threat and value
• Particularly concerned with the status of
the self.
• Directly connected to sensory and body
subsystems
A challenging model of the mind.
• The mind is simultaneously individual,
and reaches beyond the individual,
when the implicational ss. is dominant.
• This happens at high and at low
arousal.
• There is no boss system – only a
constant balancing act between logic
and emotion – human fallibility
• Mindfulness is a useful technique to
manage that balance.
Important Features of this model
• Our subjective experience is the result of two
higher order processing systems interacting –
neither is in overall control.
• Each has a different character, corresponding to
“hot” and “cool” cognition.
• The IMPLICATIONAL Subsystem manages
emotion – and therefore relationship.
• The verbal, logical, PROPOSITIONAL ss. gives
us our sense of individual self.
Taking Experience Seriously in
Psychosis
• Psychosis: when Emotion Mind/Implicational
does not mesh properly with Reasonable
Mind/Propositional
• This leads to a different quality of experience –
fine in the short term – a problem when stuck
• Normalising the difference as well as the
continuity – shared and unshared reality
• Sensitivity and openness to anomalous
experience – continuum with normality
• Understanding the role of emotion – the feeling
is real; the ‘story’ is improbable
Evidence for a new normalisation
• Schizotypy – a dimension of experience: Gordon
Claridge.
• Mike Jackson’s research on the overlap between
psychotic and spiritual experience.
• Emmanuelle Peter’s research on New Religious
Movements.
• Caroline Brett’s research: having a context for
anomalous experiences makes the difference between
– whether they result in diagnosable mental health difficulties
– whether the anomalies/symptoms are short lived or persist.
• Wider sources of evidence – e.g.Cross cultural
perspectives; anthropology. Richard Warner: Recovery
from Schizophrenia.
The Everyday
• Ordinary
• Clear limits
• Access to full memory
and learning
• Precise meanings
available
• Separation between
people
• Clear sense of self
• Emotions moderated and
grounded
• A logic of ‘Either/Or
The Transliminal
• Numinous
• Unbounded
• Access to propositional
knowledge/memory is
patchy
• Suffused with meaning or
meaningless
• Self: lost in the whole or
supremely important
• Emotions: swing between
extremes or absent
• A logic of ‘Both/And’
The Next step
• The formulation shows what is going
wrong – and how it remains stuck
• The formulation becomes the guide for
exploring ways forward
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
Psychological Group Programmes.
(complement the individual work)
Dialectical Behaviour Therapy based Emotional Coping
Skills Group – 6 session rolling programme.
The Making Friends with Yourself Group
• This is a 3 session Self Esteem Programme
• Based on ‘Compassionate Mind’ approach
The What is Real and What is Not Group
• 4 session psychosis (voices and other symptoms)
programme
• Based on the idea of normalising anomalous
experiences and so reducing stigma
‘Your Safety System; a users’ guide’.
• Manual based arousal management programme for
delivery by nursing staff following training.
Working with Psychosis using this
Model
• Managing arousal – Reasonable
Mind/Propositional is less accessible at
both high and low arousal
• Validate the experience
• Validate the emotion
• Persuasion to join “shared reality”
• “Sensitivity” – normalisation based on
Claridge’s work on schizotypy.
Session 2. The role of Arousal
shaded area = anomalous experience/symptoms are more accessible.
Level of
Arousal
High Arousal - stress
Ordinary, alert, concentrated, state of arousal.
Low arousal: hypnagogic; attention drifting etc.
Linehan’s STATES OF MIND applied to
PSYCHOSIS
Shared and Non-shared Reality
reasonable mind
Ordinary thinking
Shared reality.
wise
Mind –
in touch
With both
emotion mind
or open to other ways
of experiencing
Non-shared reality
in the present
in control
Discussion of Ways of coping suggested by this approach –
management of arousal and distraction.
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 Therapist 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)
Training Issues
• 1. Practical issues
– Whole-unit staff training
• 2.Issues of scepticism
– Psychological training in a medic-led environment
• 3. Issues of attitude
– Ownership of the training – (Hastings & Remington,
1995)
• 4. Issues of staff well-being
– Impact of the nature of the work – (i.e. protection from
burn out)
Issues of Scepticism
• Introduction to evidence-based psychological
approaches.
• Recognise the strengths and diversity within the
team as well as working towards a consistent,
Recovery oriented, approach.
• Promote development of positive care plans for
challenging behaviour using these approaches.
– Teaching given on behaviour principles of behaviours to
increase, rewards and reinforcements vs. behaviours to
decrease and punishment
• Be able to conceptualise challenging behaviours
in helpful ways.
Issues of attitude and ownership
• Staff ownership of the training to improve application of
the approach once training complete
• Before the training, allocated into teams of 5 and asked
to bring a current case to discuss
• Small group work to formulate the case they brought,
develop a positive care plan with clear triggers,
reinforcements and integrated opportunity for desired
change based on teaching received
• Two days spread out over two weeks
– Try out the approach in the ward environment, record the results,
and…..
– Be able to report back on and discuss the experience at the
second day.
Outcomes
• Staff valued opportunity to think
• Reduction in challenging behaviours in
some cases presented
• Concept of focusing on behaviours to
increase as opposed to behaviours to
decrease established in the unit
• Regular MDT care planning and case
discussion requested by staff
Exercise
• Identify the training needs of the unit you
work in
• What opportunities are there to deliver
this?
• What obstacles are there?
• How can you ensure the training has
lasting impact?
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)
3. Locus of Control of Behaviour Scale (LCB)
(Craig, Franklin & Andrews, 1984)
4.Goal Setting: Visual-analogue, ideographic, measure of individual
goals.
5. Living with Emotions -designed for this research. Three questions
looking at confidence in coping with emotions. Each question is scored
on a Likert scale
Mental Health Confidence Scale
70
60
Pre
Post
50
40
S c or e
30
20
10
0
Tot al score **
Opt imism
Coping **
Advocacy
Locus of Control
50
Pre
40
Post
30
S c or e
20
10
0
Int ernal **
Ext ernal
Living With My Emotions
20
Pre
15
Post
S c or e
10
5
0
Conf idence **
St rat egies **
Goal Setting Questionnaire
10
Pre
Post
S c or e
5
0
Client’s perception of how close they were
to reaching their goals **
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
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. Clinical
Psychology and Psychotherapy. 14, 117-125.
• Cognitive Behaviour Therapy for Acute Inpatient
Mental Health Units; working with clients, staff
and the milieu. Edited by Isabel Clarke &
Hannah Wilson. Routledge. June 2008
• Isabel’s website: www.scispirit.com/psychology