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

1. Designing a CBT Service for an Acute In-patient Setting:A pilot evaluation study. Caroline Durrant, Isabel Clarke, Abigail Tolland and Hannah Wilson Clinical and Assistant 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: 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.

6. 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).

7. FEAR RAGE SADNESS Nightmares: can’t sleep Cut self Attempt suicide More difficult to cope Friends and family alarmed. Could lose custody of children. Avoid going out and seeing people More time to brood Feel worse Typical formulation PAST ABUSE LOSSES PARTNER LEAVING 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

8. 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.

9. 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)

10. 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 • 1:1 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

11. 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.

12. 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.

13. 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.

14. Pre Post Mental Health Confidence Scale

15. Pre Post Locus of Control

16. Pre Post Living With My Emotions

17. Pre Post Goal Setting Questionnaire Client’s perception of how close they were to reaching their goals **

18. 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.

19. 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.

20. Locus of Control Scale: Most recent results, n=24

21. Living with emotion scale (Confidence): Most recent data, n=37

22. Locus of Control Scale: Most recent results, n=24

23. 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

24. 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.

25. Contact Details and References • Isabel.Clarke@hantspt-sw.nhs.uk • Hannah.Wilson@hantspt-sw.nhs.uk • Durrant, C., Clarke, I., Tolland, A. & Wilson, H. Designing a CBT Service for an Acute In-patient Setting:A pilotevaluation 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. Isabel’s website: www.scispirit.com/Psychology/