Designing a CBT Service for an Acute In-patient Setting: A pilot evaluation study.

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Designing a CBT Service for an Acute In-patient
SettingA pilot evaluation study.

• Caroline Durrant, Isabel Clarke, Abigail Tolland
  and Hannah Wilson
• Clinical and Assistant Psychologists from AMH
  Woodhaven.

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The challenge of therapy delivery

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

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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

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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.

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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 Teasdale Barnard 1995)
• A Third Wave Cognitive therapy focus on
  intervening between thought and feeling rather
  than altering thought to effect feeling (Hayes et
  al. 1999)
• Management of arousal (breathing control), and
  mindfulness training to facilitate intervention
  in the cognitive/emotional process.

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Therapy approach continued

• 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
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Psychological Therapies at Woodhaven wider role

• The other activities of the Woodhaven
  Psychological Therapies Service complement the
  individual therapy delivery and will contribute
  to the outcomes.
• Work with staff and the institution
• DBT programme, involving a multidisciplinary
  team, and delivering a cross diagnostic group
  programme
• Other psychological group programmes A
  compassionate mind approach to self esteem The
  Making Friends with Yourself group, and a
  psychosis group The What is Real and What is
  Not Group.
• An anxiety and stress management programme to be
  delivered by nursing staff following training.

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Working with staff

• 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)

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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
• 6 week Emotional Coping Skills (ECS) group
• Chain analysis after incidents of self harm
• 11 weekly therapy following the DBT model and
  Individual skills training for BPD individuals
  with extended stay on the Unit.
• Risk management advice
• Staff training and education
• Consult team for support and supervision

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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.
• We only managed to collect 16 completed data sets
  during this period usual problems with Time 2
  data collection.
• 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.
• 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.
  
• 4.Goal Setting Visual-analogue, ideographic,
  measure of individual goals.
• 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.

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Mental Health Confidence Scale
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Locus of Control
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Living With My Emotions
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Goal Setting Questionnaire
Clients perception of how close they were to
reaching their goals
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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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Keeping up the Evaluation

• Measurement has continued, but without an
  assistant, data collection has been harder to
  maintain consistently. Results since the end of
  the study continue to be encouraging.
• A summary follows.

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Locus of Control Scale Most recent results, n24
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Living with emotion scale (Confidence) Most
recent data, n37
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Locus of Control Scale Most recent results, n24
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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.
• 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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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. Clinical
  Psychology and Psychotherapy. 14, 117-125.
• Forthcoming book Cognitive Behaviour Therapy
  for Acute Inpatient Mental Health Units working
  with clients, staff and the milieu. Edited by
  Isabel Clarke Hannah Wilson. Routledge.
• Isabels website www.scispirit.com/Psychology/