The Challenge of a psychological therapies service in an acute inpatient unit.

1
The Challenge of a psychological therapies
service in an acute in-patient unit.

• Isabel Clarke and Hannah Wilson
• Clinical Psychologists from AMH Woodhaven.

2
The challenge of therapy delivery

• Variable and unpredictable admission times
• Mixed diagnoses
• Time of crisis
• Risk factors

3
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

4
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.

5
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.

6
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).

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Typical formulation
PAST ABUSE LOSSES PARTNER LEAVING
WAYS FORWARD Dont 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
8
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.

9
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
  multi-disciplinary care planning meetings (to be
  implemented)

10
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.

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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.

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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 ones 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.

13
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.

14
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

15
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.

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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

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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.

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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.

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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
• 11 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

20
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

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Contact Details and References

• Isabel.Clarke_at_hantspt-sw.nhs.uk
• Hannah.Wilson_at_hantspt-sw.nhs.uk
• Durrant, C., Clarke, I., Tolland, A. Wilson, H.
  Designing a CBT Service for an Acute In-patient
  SettingA 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.
• Isabels website www.scispirit.com/Psychosis_Spir
  ituality/