The Role of the Psychologist in an Early Intervention in Psychosis Team Dr Janice Harper, Consultant Clinical Psychologist Esteem, Glasgow, UK. Ferrara, Italy, 5 th May 2017
Overview Essential Components of an EIP team Role of Clinical Psychology in EIP Facilitating Psychologically Informed Care in MDT Psychological Therapies in EIP Benefits of psychological care integrated in team
Leverndale Hospital Grounds
Essential Clinical Components Of EIP Team Staff trained in EI approach and interventions Integrated Care Pathway to guide and ensure fidelity True MDT work incorporating all disciplines Comprehensive MDT assessment including Developmental history from family members Assessment of family functioning Formulation driven care plan Family work including formal therapy where indicated Intensive support and outreach to enhance engagement Crisis function
Guidelines on Psychology Within EIP Teams UK and National Guidelines all require access to psychological therapies for patients with psychosis (SIGN, NICE) Guidance for EIP services include at least 1 clinical psychologist per team - and other psychological therapists (Sainsbury, BPS) Multidisciplinary Team (MDT) with Psychologically Informed Care
Role of Clinical Psychologist in EIP Team Facilitating Psychologically Informed Care in the team Service Planning Research and audit Training and Supervision Team Formulation Care planning Direct Clinical Work- individual and family psychological therapies
Service Planning As members of the senior staff group senior clinical psychologists are involved in all service planning to ensure that psychosocial factors are considered in all aspects of care and approval of all new developments in the service, e.g. OT groups, physical health plans The psychologist has clinical governance of psychological interventions offered within team/service, e.g. low intensity psychological interventions, family therapy, group therapy.
Research and Audit In the Uk all clinical psychologists are trained to doctoral level which includes a formal research study This knowledge and skill facilitates ongoing research within the team The team psychologists often supervise trainee psychologists carrying out their research with participants who are patients or staff in the team Team psychologists carry out audits of various aspects of the team work e.g. Substance misuse, Parental mental health issues Provides other members of the team with guidance on the use of research, evaluation, standardised measures
Consultancy and Supervision Being part of the team and being available in the team base allows individual team members and the team as a whole to easily consult on psychological aspects of care Promoting the psychological understanding of specific presentations, e.g. complex cases, personality, developmental issues, e.g. ASD Facilitating understanding of team reaction to clinical situations/individuals/families Supervision of psychological interventions carried out by other staff members, individual and group supervision
Team Training Programme in Psychological Interventions Topics Forming collaborative relationships including endings and transitions Trauma disclosure Distress tolerance skills/ stabilisation skills Relapse prevention Psychoeducation Psychosocial interventions with psychotic symptoms Working with comorbidities Working with substance misuse Understanding ASD Parental mental health
Team Formulation The Psychologist facilitates a team formulation for every patient within the service following the initial team assessment. Underpinning principles of the formulation Biopsychosocial and stress/vulnerability frameworks focus on how behaviour, experiences and beliefs of people with psychosis may be shaped by biological but also psychological and social factors Recognises that psychosis is an emotional disorder A cognitive behavioural therapy model is utilised
Team Formulation - Key elements Formulation is a bridge between assessment & planning an individually-tailored treatment Captures the complex and individual nature of people s experiences The way people adapt to, or cope with, their life circumstances and psychotic experiences are of central importance Summarises the patients core problems through developing a shared understanding of the nature of the individual s problems and forms the basis of care planning Aims to explain the development and maintenance of the patients difficulties, at this time and in these situations
Team Formulation - Key elements Forum for thinking creatively, permitting new perspectives to emerge, linking theory & practice Explanatory frameworks for client s presentation effect behavioural, emotional, attitudinal responses in staff Draws on skills and expertise of all team members and all are encouraged to contribute ideas Informs decisions about interventions Open to revision and re-formulation.
5 Ps Formulation Presenting problems: what does the individual/family want to change? Predisposing factors: what factors have contributed to the problem? Genetic? Family history? Trauma in early life? Precipitating factors: what triggers the problem? Perpetuating factors: what keeps the problem going? Protective factors: what helps?
Ongoing Review of 5p s Team Formulation 1 hour time slot which creates pressure Need to be wary of a focus on diagnosis/symptoms The internal personal impact/meaning/ appraisal of external events can be neglected For complex cases interactions & dynamics between factors can be under-developed in the 5 P s formulation Sometimes a lack of information for difficult to engage patients The 5 Ps is a preliminary formulation during early phase At each review the formulation is revisited For patients who are at risk of arrested recovery we have been implementing a Compassion Focused Therapy Formulation
The Role of the Psychologist in EIP team Direct Clinical Work
Psychosis : an Emotional Disorder Traditionally emotional problems were incorrectly viewed as less important than core psychotic symptoms Depression is at the core of psychosis for a large group of people Psychosis can arise from a disturbed development High incidence of adverse childhood experiences Evidence from neuropsychology of changes in brain structure and chemistry following emotional distress Emotional problems as a psychological reaction to psychosis Post psychotic depression, PTSD Social anxiety and shame of Psychosis Distress from psychotic symptoms depends on significance and meaning not severity of symptoms
Psychological therapies for Psychosis Aims to help people work out their own understanding of the nature of their difficulties and what is likely to help. Based on a collaborative working relationship between the therapist and the individual/family. There is strong evidence that psychological interventions are effective in reducing psychotic experiences and the distress and disability they cause, Psychological interventions, alongside social interventions (psychosocial interventions), can reduce relapse rates by 50% Psychological therapies include CBT, family therapy, and many other psychological approaches
Direct Clinical Work of EIP Psychologist Early in care pathway Assessment to help determine presence of psychosis where this is unclear Intervention with family members who may be a barrier to recovery Therapy where the client is unwilling to take medication Neuropsychological assessment where indicated Following Team Formulation Identified as in need of psychological therapy Family Therapy
Target for Psychological therapies for Psychosis Symptom focused targeting hallucinations, delusions, negative symptoms such as lack of motivation, lack of pleasure. The consequences of Psychosis including depression, anxiety, low self esteem, social consequences, trauma of psychosis, fear of relapse, cognitive deficits (problems with memory, concentration), interpersonal and family problems Co-existing problems including substance misuse, eating disorders, OCD, Pre-existing problems which may have contributed to a persons vulnerability to psychosis, e.g. Low self esteem, personality difficulties, family dysfunction Emotional Recovery Family Interventions
Initial assessment for presence of psychosis in complex presentations 25% of Esteem psychology s direct clinical work is in assessment of patients suitability for Esteem. This is typically required where psychosis is unclear and there are differential diagnosis including developmental disorders. Personality Disorders; Trauma; Dissociative symptoms; Learning difficulties/disabilities; Autistic Spectrum Disorders (ASD); Neurological disorders/impairment.
Case Study:Personality disorder or Psychosis or Both Male 28 lives with older female partner and step children- No previous mental health history recorded Initial thoughts psychosis but very bizarre presentation histrionic emotionally dependant on partner- psychology assessment required Medication didn t help later discovered he had not been taking meds when found out he denied Very challenging in sessions no eye contact- at times aggressive- told unbelievable stories- when challenged about this he accepted and we focused on the underlying abandonment and loss ready to refer onto a psychotherapy service In the mean time further psychology sessions - although histrionics reduced he still insists on distress re voices recently agreed to try medication properly Current theory is histrionics influenced his presentation of real psychotic symptoms in a way that made them seem false He is now offered weekly psychology sessions in combination with medication We will see..
Snap shot of Psychological Therapy Caseload Assessment to aid team work Female, 27 - Query intellectual functioning Engagement and neuropsychological assessment Female, 17 - Query cognitive deficits related to disorientation and poor visuospatial skills Engagement and neuropsychological assessment Query Psychosis Male, 19, Presents with voices, immature, attachment issues, low self esteem, psychosis in doubt extended assessment and therapy to establish true nature of difficulties Male 30, Presents with voices, histrionic query personality disorder Extended assessment and family work Male 24, Presents with voices, suicidality, premorbid immature personality, complex family dynamics extended assessment and Family work to address barriers
Ongoing Psychosis Male 20, Paranoid delusions and voices in context of Aspergers syndrome, Co-morbid substance misuseassessment, therapy to address intrusive thoughts and social anxiety, recent involvement of specialist ASD psychologist Male 28, Paranoid delusional disorder, no insight, slow engagement focus on self esteem Male, 23, Delusions in context of complex early childhood trauma and recent trauma in family delusional beliefs resolving CBT and trauma work
Psychosis resolved with Medical Treatment Male 35, Paranoid psychosis, 2 episodes, resolved- therapy to address psychological vulnerabilities to relapse, - issues related to sexuality and core beliefs schema therapy Male 22, Acute psychosis severe, now resolved, - complex trauma and abandonment in childhood, therapy to reduce psychological vulnerabilities to relapse including suspected ongoing threats within family -not yet disclosed. Male 24, Psychosis resolved - therapy to address comorbid depression - disclosed gender dysphoria and wish to transition to female therapy to support Male 30 s, Paranoid psychosis with OCD, stable on medication, CBT to address social anxiety and OCD Male 17, Acute psychosis, resolved with hospital and medication, assessment of psychological vulnerabilities to reduce risk of relapse Male 30, Paranoid psychosis, resolved, ongoing depression and comorbid substance misuse slow/difficult to engage
Male 22, Acute psychosis resolved, query ASD, ongoing social and family problems assessment phase Female, 27, Psychosis resolved, Co-morbid Learning Disability Cognitive assessment and behaviour therapy to address levels of functioning and self esteem. Female 25, Bipolar disorder with psychosis, resolved, therapy to address low mood and psychological vulnerabilities to relapse Female, 28, Bipolar disorder with paranoid delusions resolved assessment and therapy to address mood- now reformulated with comorbid emotionally unstable personality disorder, therapy to address this Female 28, Dissociative, Voices, Paranoia, - CBT for PTSD I and II, symptoms resolved stable on medication ending therapy Couple, 30 s, Psychosis and bi polar, currently well couple therapy including sensate focus to address the impact on relationship and reduce risk of relapse
Direct Clinical Work Observations Very little need for CBTp - cbt for voices Ongoing psychosis in those with delusional disorder little insight as yet so focus on underlying issues Large degree of early childhood trauma Large degree of pre-morbid low mood, social anxiety Significant degree of co-morbid personality disorder likely early trauma/attachment issues Most assessments will involve meetings with family members.
Benefits of psychologists integrated in EIP teams Allows a true biopsychosocial approach Focus on integrated multidisciplinary work Easy access to psychological therapy Psychological assessment early in pathway Multidisciplinary assessment prepares the patient and psychologist for therapy Simultaneous work with other disciplines in the team supports psychological intervention and vice versa Range of psychological interventions delivered by all members of team Allows a focus on skills development for all team staff
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