Dr. Sean Harper-Consultant Clinical Psychologist DCP/PCMH March 2017

Transcription

1 Dr. Sean Harper-Consultant Clinical Psychologist DCP/PCMH March 2017

2 Overview of the model for Acute service Research Implementation Conclusions and forward planning

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4 Charlotte Patterson-PhD Student (Edinburgh Napier University) Dr. Ruth Lennon-Clinical Psychologist (NHS Lothian) Assoc. Prof. Paul Hutton (Edinburgh Napier University) Prof. Thanos Karatzias (Edinburgh Napier University) Dr. Helen Griffiths (Edinburgh University) Dr. Rosie Stenhouse (Edinburgh University) Dr. Adele Dickson (Glasgow Caledonian University)

5 Kaizen re-design of acute service 1. Staff 2. Carers 3. Service Users

6 Target Staff Training Staff Support Patient access to individual psychological formulation and therapy Patient access to therapeutic groups Creating a therapeutic environment

7 CBT model for acute care developed by Isabel Clarke et al (2009) Mentalization Based Therapy skills training based on the work of Bateman & Fonagy (2004). Staff Reflective Practice Staff Clinical Supervision in MBT and CBT

8 Philosophy of the approach

9 This approach gives the service user the following message: 1.Their distress is understood and taken seriously (validation). 2.They have a vital part to play in doing something about it. (Change). It Motivates to take responsibility It orients the individual towards a therapeutic (as opposed to a purely medical) approach.

10 Aims towards working with high states of arousal identifies the individual s relationship to feeling awful inside as the problem. Introduces approaches to change that can be supported by other members of the team (distributed) Or supported by the therapist at flexible intervals.

11 Less beds give service users a Recovery message from the outset. Culture change model Integrate psychological treatment at the heart of the MDT approach service users asking for talking treatment Build a psychologically minded workforce Increase staff morale opportunity to participate actively in psychological treatment psychological rationale Aims to include all of the MDT to work in a consistent way within the model to maximise effectiveness and to develop a therapeutic milieu within an in-patient environment

12 Patients: Will have access to a psychological understanding and formulation from entry point into acute service Will have access to individual, formal short term therapy for duration of in patient stay Will have access to group therapeutic interventions determined by the psychological formulation

13 Staff: Will have training in psychological principles and specific training relating to the proposed model allowing opportunity to work within the model and co-facilitate therapeutic groups Will have support in their work through reflective practice and clinical case consultation

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15 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

16 The fast track, emotion mind, looks out for information about threat (and value) and gets the body ready for action when it senses threat This switches attention away from the bigger picture and onto looking for threat Emotion mind manages relationship both with ourselves and with others It constantly monitors how we are doing we register this monitoring as feeling.

17 Because our brains have 2 main circuits they work together most of the time, but not always. One gets us ready for rapid action The other thinks about things Similarly there are 2 types of memory The emotional memory stores memories of threat and produces them when things are bad as if they were happening now trauma Mindfulness/Attentional Control enables us to hold the two parts in mind together.

18 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 People develop ingenious ways of avoiding emotion

19 REASONABLE MIND Reasonable Mind Memory WISE MIND EMOTION MIND Emotion Mind Memory IN THE PRESENT IN CONTROL

20 The human being is a balancing act as the two organising systems pass control back and forth It is not that one system is in control. The mind is both individual, and reaches beyond the individual, when the emotional mind is dominant. This constant switch between logic and emotion gives us human fallibility The self sufficient, independent, rational mind is an illusion In our emotional mind we can be part of the whole and the nature of our experience changes. We have access to two, distinct, ways of knowing

21 Client:..yes I know exactly what you are saying and I can understand that I am not to blame for the abuse I have experienced, but it still feels like I am to blame

22 Thinking about relations in CBT may be divided into three dimensions: Ourselves Others (MDT staff, patients, family members) System (Acute Service, The NHS) The key point is the interaction or transactions between all of these dimensions.

23 MY REASONABLE MIND RM Memory MY EMOTION MIND EM Memory WISE MIND YOUR REASONABLE MIND YOUR EMOTION MIND IN THE PRESENT IN CONTROL

24 Offering one to one time with key worker approaching emotional experience rather than avoiding it Key workers/staff can use MBT skills to validate experiences, encouraging acknowledgement of emotional distress, and engage with patients Reflective Practice Case consultation

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26 Acute Distress/Crisis conceptualised at the centre of the problem Presenting problems are then formulated using functional analyses/vicious cycles Short term function-longer term perpetuating emotional distress Relational Interactions are also considered to inform formulations

27 Emotion Focussed and Relational Functional Analysis Formulation. Past:abuse, trauma etc. Try to escape from the emotion by avoidance, self harm. Separation from partner Feel better short term Bad longer term Consequences e.g. observation Distress concern from family. Anger Fear Sadness Distress after phone call to relative Shouting on ward Asked by staff to keep the noise down Increase in shouting/distress (Relational Factors)

28 Individual and Group therapies 1:1 time with staff Care plans reflecting formulations

29 3 therapy groups available on the ward Anxiety management Group Emotion regulation group Compassionate Friend Group Mindfulness

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31 Timeframe June 2014 to April 2016 Total patients seen for individual therapy 99 Clinical sessions offered in individual therapy 379 hours In addition access to three therapy groups-approx-185 hours Community Links/Referrals Improved pathways

32 Ruth Lennon, Helen Griffiths, Sean Harper NHS Lothian, The University of Edinburgh

33 Difficulties in emotion regulation (ER) have been identified as a trans-diagnostic factor across mental health difficulties (Mansell et al., 2009). Emotion dysregulation is a well established core feature of personality disorders and mood disorders. More recently, research has focused on the role of affect and emotion dysregulation in psychosis.

34 Trans-diagnostic group, specifically designed for acute setting. Adapted from DBT, ACT and mindfulness principles. 6-Session rolling and open group. 6 different emotion regulation topics covered Group offered twice weekly on the ward. Research data collected over a six-month period.

35 Audit Data Doctoral research data

36 Living Well with Emotions Audit Data Length of time group was offered over Over 6 months Total no. group session offered 30 Total no. group sessions attended 26 Total no. individuals who attended 1 or more group sessions 29 Female 20 Male 9 Range of no. of group sessions attended 1-10 Mean no. group session attended 2.4

37 29 individuals attended over 6 month period Individuals on average attended 2 group sessions

38 Group attrition defined as individuals remaining in the group session for at least two thirds of the group session. Attrition rate very low 6%. Indicates preliminary evidence for acceptability of the group

39 8 individuals from the ward consented to take part in research exploring acceptability and feasibility of the Living Well with Emotions Group Case series design was employed, using quantitative and qualitative data. Pilot research primarily explorative in nature. 8 consenting participants completed questionnaires prior to starting the group, at each group session, and after the group. 7 of the participants agreed to take part in a qualitative interview prior to their discharge from the ward.

40 Pre and post group measures included: DERS (Difficulties in Emotion Regulation scale) CORE-5 AAQ-II (Acceptance and Action questionnaire) REQ (Regulation of Emotions questionnaire) Case series measures (taken at each group session): AAQ-II CORE-5 Visual Analogue Scale (VAS)

41 Quantitative data Group level Results Group showed: A large effect size for changes in emotion regulation strategies (as measured by the DERS). A medium effect size for changes in emotional acceptance and distress (As measured by the AAQ-II & CORE). *All results need to be interpreted with caution due to the small sample size.

42 7 participants completed a qualitative interview exploring their perception of the group, looking at group acceptability. Data was analysed using a thematic analysis framework. Analysis resulted in the identification of 5 key themes.

43 1. Group acceptability two sub-themes: Positive Acceptability (all participants) It should be longer cause it made you want to learn more, and understand more Negative Acceptability (two participants) I Found it distressing listening to someone talk about how they ended up in hospital

44 2. Group identification I felt I had more in common with people there in the group. Cause quite often they ll say something and I ll think that was the same with me 3. Positive Functionality of the Group Hearing other people talk about ways to deal with emotions After coming to the group people felt more comfortable to chat about how they were feeling

45 4. Emotional Acceptance And now I can feel an emotion and I can say to myself it s okay. Let it go and it will pass. 5. Change And acting opposite, so instead of selfharming I could do something like self-care

46 Promising results for clinical effectiveness of the group. Results highlight that individuals found the group acceptable and suitable. Participants acknowledged change that occurred in relation to increasing their emotional acceptance and use of more effective emotion regulation strategies.

47 Charlotte Paterson ¹ Paul Hutton ¹ Thanos Karatzias ¹,³ Sean Harper ³ Adele Dickson ² ¹ Edinburgh Napier University; Glasgow Caledonian University ³ NHS Lothian

48 Study Design Study population Psychotherapy Comparator Outcome measures Randomised and non-randomised controlled trials Uncontrolled studies (case studies and case series) were excluded Participants were acute psychiatric inpatients aged between 16 and 65. No restriction on diagnosis Any talking psychotherapy. Trials where substance abuse was the primary aim of intervention were excluded All inpatient comparators. Grouped into usual treatment, inactive therapy, all controls Primary outcome: post intervention PANSS total score. Other outcomes: Follow-up PANSS total score, distress (symptoms of depression, symptoms of anxiety), readmissions.

49 Search Results Duplicate removed Excluded Total studies 512 studies from 6 data bases 14 from other sources (reference lists) 0 from trial registries studies Not in English (12) Did not meet population, treatment, comparator inclusion or design criteria (140) Incomplete data or did not report outcome measures (15) Other (3) studies which made up 20 individual trials.

50 Psychological therapy for acute mental health inpatients: A meta-analysis Table 1. Effect sizes, CIs, p-values and quality of outcome ratings for all outcomes and subgroup analyses Outcomes (k studies) N SMD or OR 95% CI Post treatment PANSS total (15) , Post treatment PANSS total , High quality (8) 0.14 Post treatment PANSS total , Low quality (7) Post treatment PANSS total , Probable contact with 0.13 therapist in control group (8) Post treatment PANSS total No probable contact with therapist in control group (7) , Post treatment PANSS total CBT (8) , Post treatment PANSS total , Third wave (5) 0.06 Post treatment PANSS total , Other (2) 0.53 Follow-up PANSS total (6) , 0.10 Follow-up PANSS total , High quality (4) 0.19 Follow-up PANSS total , Low quality (2) Readmissions (7) , (OR) 0.84 Readmissions , High quality) (4) 1.28 Readmissions , Low quality (3) 0.73 Depression (7) , Depression , High quality (3) 0.18 Depression , Low quality (4) Anxiety (4) , P 0.00 VL 0.28 VL 0.00 VL 0.35 L 0.00 VL 0.02 VL 0.09 VL 0.61 L 0.18 VL 0.91 VL 0.00 VL 0.00 L 0.40 L 0.00 L 0.01 L 0.21 L 0.01 L 0.03 L Quality rating Main findings: - Psychological therapy was significantly more effective than controls in all outcomes but follow-up PANSS. - However, study quality moderated effectiveness, particularly for psychotic symptoms. - Promising effects remained in emotional distress (depression) and readmission outcomes in high quality studies. Limitations: - Effective dose and therapy type unable to be explored due to small sample size. Implications: - Inpatient therapy should provided to those who want to receive it. Further research is needed to: - Confirm positive results found here. - Identify what type and dose of therapy is effective and for whom.

51 Large proportion of studies are not of high quality. Psychological Therapy Small to moderate benefit for inpatients in reducing overall psychotic symptoms but did not survive in high quality studies. Moderate benefit in reducing readmissions. Small to moderate benefit for inpatients in reducing distress (depression and anxiety).

52 Charlotte Paterson ¹, Sean Harper ², Thanos Karatzias ¹ ², Paul Hutton ¹, Adele Dickson ¹ ¹ Edinburgh Napier University; ² NHS Lothian

53 Design: Non-randomised controlled trial to evaluate the effectiveness of a cross diagnostic CBT based model of acute inpatient care. Hypothesis: Psychological therapy plus TAU will be more effective than TAU in reducing readmissions and distress and increasing self efficacy.

54 Assessed for eligibility (n=273) Excluded (n=177): Declined: (n=158) Discharged/moved wards 2 days after admission (n=14). Unable to meet for baseline assessment in time (n=4). Not acute inpatient (n=1). Completed baseline assessment Control group N=40 Intervent ion psych N=30 Intervent ion no psych N=26 Excluded after entering study Current number N=7 N=2 N=6 N=33 N=28 N=20 Excluded: Discharged or moved ward within 3 days of baseline assessment (n=14). Staff lost questionnaires (n=1).

55 Demographic and clinical characteristics Diagnostic prevalence: Psychosis Schizophrenia Personality disorder Depression Bipolar Disorder Unknown Ages median (range) Gender: M F Previous admission: Y N Control group (n=33) 15% (n=5) 12 % (n=4) 15% (n=5) 22% (n=7) 33% (n=1) 3% (n=1) Intervention group 1 (psychology) (n=28) 7% (n=2) 29% (n=8) 7% (n=2) 25% (n=7) 32% (n=9) 0% Intervention group 2 (no psychology) (n=20) 5% (n=1) 40% (n=8) 20% (n=4) 5% (n=1) 20% (n=4) 10% (n=2) 43 (26-63) 43 (21-62) 43.5 (28-62) 36% (n=12) 64% (n=21) 58% (n=19) 39% (n=13) 54% (n=15) 46% (n=13) 57% (n=16) 43% (n=12) 50% (n=10) 50% (n=10) 75% (n=15) 10% (n=2)

56 As assigned (assuming missing data MCAR but excluding treatment drop-outs) Mean SD gain change N t-value (p-value) d (95% CI) Summary CORE-10 total Intervention (p=0.10) (-0.98, 0.09) Moderate, NS Control CORE-10 Problems Intervention (p=0.13) (-0.94, 0.11) Moderate, NS Control CORE-10 Functioning Intervention (p=0.14) (-0.93, 0.13) Moderate, NS Control BSI Total Intervention (p=0.02) (-1.20, -0.13) Moderate-large, Sig Control BSI Somatization Intervention (p=0.01) (-1.28, -0.22) Large, Sig Control BSI Anxiety Intervention (p=0.06) (-1.05, 0.02) Moderate, NS Control BSI Depression Intervention (p=0.10) (-0.98, 0.08) Moderate, NS Control MHCS total Intervention (p=0.13) 0.41 (-0.11, 0.94) Moderate, NS Control MHCS Optimism Intervention (p=0.14) 0.40 (-0.12, 0.93) Moderate, NS Control MHCS Coping Intervention (p=0.58) 0.15 (-0.38, 0.67) Small, NS Control MHCS Advocacy Intervention (p=0.24) 0.32 (-0.21, 0.84) Small, NS Control

57 As assigned (assuming missing data MCAR but including treatment drop-outs) Pre treatment Post treatment Mean SD gain N M SD M SD change t-value (p-value) d (95% CI) Summary CORE-10 total Intervention (p=0.77) (-0.48, 0.39) No effect Control CORE-10 Problems Intervention (p=0.79) (-0.48, 0.39) No effect CORE-10 Functioning Control Intervention (p=0.78) (-0.49, 0.38) No effect Control BSI Total Intervention (p=0.34) (-0.64, 0.23) Small, NS Control BSI Somatization Intervention (p=0.38) (-0.62, 0.25) Small, NS Control BSI Anxiety Intervention (p=0.28) ( ) Moderate, NS Control BSI Depression Intervention (p=0.77) (-0.49, 0.38) No effect Control MHCS total Intervention (p=0.20) 0.26 (-0.18, 0.70) Small, NS Control MHCS Optimism Intervention (p=0.22) 0.21 (-0.22, 0.65) Small, NS Control MHCS Coping Intervention (p=0.56) 0.11 (-0.33, 0.54) Trival, NS Control MHCS Advocacy Intervention (p=0.30) 0.22 (-0.21, 0.66) Small, NS Control

58 Appears that psychological interventions may be effective in reducing symptoms/distress and improving emotion regulation for individuals during acute AMH admissions Appears that clients find psychological interventions acceptable No empirical evidence of positive impact on milieu Relapse rates still to be ascertained

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60 Minimum 0.5FTE Psychologist/Psychological Therapist per ward (AIMS- Royal College of Psychiatry) Full bio-psychosocial model is implemented in patient care such that psychological factors are given equal weight in their explanatory power as biological factors. All patients to be informed of and offered psychological approaches to formulation and associated individual and group therapies on entering the ward. That nursing care plans and all associated acute service paperwork reflects psychological factors and formulation as a core element in patient care planning. Ward rounds and all care planning meeting are Multi Disciplinary. As such this should include a psychological presence at all patient care meetings. That nursing staff are given protected time to deliver individual and group therapeutic work Staff are supported to attend training and provided with protected time to attend supervision and reflective practice. Further research/audit is encouraged to ensure that the implementation strategy is achieving desired outcomes

61 Successful implementation requires an agreement from all members of the MDT that psychological and social factors will be considered equitably in the acute service... and that there are associated implications for practice

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64 On going/planned research: Staff experience Evaluation of Reflective Practice Relapse rates for those receiving psychological therapy as inpatient Future areas What sorts of individual/group therapies are most effective/dosage? Group therapies-effective components? Exploring the client group who do not engage-profiles can we begin to understand these clients psychological needs/interests? Individual/Team Formulation Impact in acute environment More robust trials in acute service generally

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