Services for People with Severe and Enduring. Mental Illness

The British Psychological Society Clinical Psychology in Services for People with Severe and Enduring Mental Illness The British Psychological Society Division of Clinical Psychology Briefing Paper No. 18 Clinical Psychology in Services for People with Severe and Enduring Mental Illness St Andrews House 48 Princess Road East Leicester LE1 7DR, UK Tel 0116 254 9568 Fax 0116 247 0787 E-mail mail@bps.org.uk http://www.bps.org.uk Incorporated by Royal Charter Registered Charity No 229642 August 2002

Contents 1. Introduction...1 2. Client group who is this service provided for? A note on terms...1 3. Extent of psychological need and demand...2 4. The roles of clinical psychology...2 5. Core components and service organisation...4 6. References...5 Other titles in this series...5 Clinical Psychology in Services for People with Severe and Enduring Mental Illness is published by The British Psychological Society, St Andrews House, 48 Princess Road East, Leicester LE1 7DR. August 2002 ISBN: 1 85433 382 6 This guide was prepared by Simon Gelsthorpe in consultation with the committee and members of the Psychosocial Rehabilitation Special Interest Group, Division of Clinical Psychology,The British Psychological Society. Copies of this briefing paper are available from the Society s Leicester office. Members of the DCP 3.75, non-members 5.00.

1. Introduction This briefing paper is intended for use by clinical psychology service managers and commissioners of services (both in Health and Social Care). It provides information on the role and function of clinical psychologists with people with severe and enduring mental illness. It endeavours to take into account, as far as possible, recent health service initiatives, and to offer clear guidance on how to structure clinical psychology within services to people with severe and enduring mental illness. 2. Client group who is this service provided for? A note on terms We have used the Department of Health terminology severe and enduring mental illness as used in the National Service Framework.This acts as a verbal shorthand and is widely understood. However we want to highlight that there is considerable debate as to whether there is an underlying illness. Rather we would stress the need for a psychological model to shape psychological treatments. The Department of Health s (1999) National Service Framework for Mental Health (NSF) set two standards for severe mental illness (Standards 4 and 5 Effective Services for People with Severe Mental Illness) stating that these standards were aimed at people with recurrent or severe and enduring mental illness who have complex needs which may require the continuing care of specialist mental health services working effectively with other agencies (NSF p.43). It consists of the rehabilitation/recovery, home treatment, assertive outreach, crisis resolution, and early intervention services. 1

3. Extent of psychological need and demand The Sainsbury Centre for Mental Health report Keys to Engagement (1998) gave prevalence rates for severe and enduring mental illness as 300 1500 per 100,000 of the adult population. Due to the very nature and definition of severe and enduring mental illness psychological difficulties are common to all people with severe and enduring mental illness and, therefore, people need to have access to specialist clinical psychology help.this was enshrined in the National Service Framework as a performance assessment criterion access to psychological therapies (NSF p.66). The NICE schizophrenia guidelines recommend the use of psychlogical interventions (Cognitive Behaviour Therapy and Family Interventions) in the treatment of schizophrenia. As well as this obvious need, demand for psychological treatments from bodies such as MIND, the Hearing Voices Network and The Mental Health Foundation has recently increased.this may be driven by a desire for types of help which have fewer unwanted effects than medication, treatments that address underlying causes and maintaining factors and that clients can be more actively involved in, and a dissatisfaction with a lack of response to drug treatment. 4.The roles of clinical psychology Specialist clinical psychology help for this client group is usually provided as part of multidisciplinary services in rehabilitation/recovery, home treatment, assertive outreach, crisis resolution and early intervention.these involve a range of professions whose task is to integrate their different perspectives and skills for the benefit of clients. Commissioners need to ensure that there is the right balance of skills within these teams working with people with severe and enduring mental illness. In particular that medical approaches are complemented by psychological approaches from clinical psychologists (NSF p.66). The work of a clinical psychology service can be seen as having four main aspects.they are: direct clinical work with clients, indirect clinical work (advising other carers on the psychological aspects of care, teaching and supervision of other disciplines about psychological approaches), clinical research, and management and administration. Direct Clinical Work Research has shown that psychological treatment can be helpful to people suffering from delusions, hallucinations, disturbed behaviour, severe emotional problems and disorders of thinking by providing evidence for Cognitive Behaviour Therapy, early interventions in psychosis, psychosocial interventions (PSI), relapse prevention monitoring, and psychological approaches to working with families. (See Rector & Beck (2001), Gould, Mueser, Bolton, Mays & Goff (2001), Pilling et al. (2002a) and Pilling et al. (2002b)). Clinical Psychologists in the UK such as Garety, Fowler, Kuipers,Tarrier, Haddock, Drury and Birchwood have been at the forefront of this research; for example Kuipers et al. (1997),Tarrier et al. (1999) and Drury et al. (1996). 2

In addition clinical psychologists can help with the disabling secondary emotional effects triggered by these primary mental problems. Indeed clinical psychologists are well placed to assess this social disability, particularly concerning psychological functioning.this type of psychological analysis is crucial to helping people overcome this secondary social disability. However the ability to do this analysis is dependent on a broad and comprehensive training in psychological models and methods. (See British Psychological Society, 2000). Indirect Clinical Work: Advice/Consultancy,Training and Supervision Many people with severe and enduring mental illness already live with full time or part time carers. These can be family, relatives, or professionals.these people have the greatest contact with the client, but do not have the clinical psychologist s broad training in psychological methods and models. As a result it is often more helpful for clinical psychologists to assist such staff/carers make more use of psychological methods. This indirect clinical work can take the form of advising carers on the care of a specific person, doing general training on psychological approaches for carers, and through advising carers about psychological care but not relating this to a named individual. Indirect clinical work is always aimed at ensuring that care is as psychologically informed as possible. It is recognised that this category of work is particularly valuable in this speciality. Helping carers to look after relatives is the focus of Standard 6 of the NSF Caring about Carers. Research and Evaluation Clinical psychology techniques are the result of clinical research and have research evidence to support their efficacy. In addition, clinical psychologists research and statistical skills make them well placed to undertake service audit and evaluation and thereby ensure that service quality and clinical outcome are measured. Continued research and evaluation should be a core activity of any clinical psychology service to ensure continued quality and effectiveness. Management, Service Development and Administration Besides the usual service management duties, clinical psychologists broad training in psychological models and skills equips them to manage multidisciplinary teams working with people with severe and enduring mental illness. The assessment skills of clinical psychologists mean they are often able to advise management or purchasers on service development issues. 3

5. Core components and service organisation Staffing levels The service should be headed by a Grade B clinical psychologist who would be responsible for developing and managing the provision of the service. Staffing levels will depend on local needs and service developments. However, it is recommended that in addition to the lead Grade B, the service for an average population district of 400,000 would need a minimum of four Grade A clinical psychologists which would include full time clinical psychology input to services of home treatment, assertive outreach, and early interventions. This staffing of the specialty is in addition to those clinical psychologists providing generic adult mental health services and reflects the importance of providing specialist clinical psychology services for this client group and the differing skills that may be required. Organisation and quality monitoring Postholders should be encouraged/expected to work within the usual multidisciplinary services while retaining clear links with their own profession to ensure clarity of roles and quality of work through a framework of professional clinical governance.the optimum organisation of clinical psychology services has proved to be a multi speciality clinical psychology department hosted by an appropriate Trust. Such an organisation ensures ongoing training and supervision following the British Psychological Society s Guidelines on Continuing Professional Development. Clinical psychologists are usually expected to carry a direct clinical caseload. However it is expected that the size of this caseload may decrease as seniority increases and the indirect clinical casework and training and supervision load increases.this would reflect an efficient use of what is still a scarce resource. The efficient use of clinical psychology time in this specialism requires the right balance between the four types of work outlined above. Local need may determine this also. Recruitment to the speciality can be a problem.the explicit commitment to support research may help to overcome this difficulty, as would the provision of split posts (including with university departments), under which the postholder devotes some sessions to another speciality of their interest. Service Standards Employs chartered clinical psychologists with experience of the client group Makes provision for supervision and Continued Professional Development following BPS guidelines Gives clients the same clinical psychologist over time Covers the range of services required Is easily accessible to all Has readily available information about the service that is easily understood Follows the professional and ethical guidelines of the BPS and DCP Has adequate clerical support Gives clients a choice of clinical psychologists and therapeutic approaches. 4

6. References British Psychological Society (2000). Recent advances in understanding mental illness and psychotic experiences. Leicester: British Psychological Society. Department of Health (1999). National Service Framework for Mental Health. London: Department of Health. Drury,V., Birchwood, M., Cochrane, R. & McMillan, F. (1996). Cognitive Therapy and recovery from acute psychosis: A controlled trial. British Journal of Psychiatry 169, 593 601. Gould, R.A., Mueser, K.T., Bolton, E., Mays,V. & Goff, D. (2001). Cognitive therapy for psychosis in schizophrenia: an effect size analysis. Schizophrenia Research, 48(2 3), 335 342. Kuipers, E., Garety, P., Fowler,D., Dunn,G., Bebbington,P., Freeman,D. & Hadley (1997). London East Anglia randomised controlled trial of cognitive-behavioural therapy for psychosis. British Journal of Psychiatry 171, 319 327 Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Orbach, G. & Morgan, C. (2002a). Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32(5), 763 782. Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Martindale, B., Orbach, G. & Morgan, C. (2002b). Psychological treatments in schizophrenia: II. Metaanalysis of randomised controlled trials of social skills training and cognitive remediation. Psychological Medicine, 32(5), 763 782. Rector, N.A. & Beck, A.T. (2001). Cognitive behavioural therapy for schizophrenia: an empirical review. Journal of Nervous and Mental Disease, 189(5), 278 287. Sainsbury Centre for Mental Health (1998). Keys to Engagement. London: Sainsbury Centre for Mental Health. Tarrier, N.,Wittkowski,A., Kinney, C., McCarthy, E., Morris, J. & Humphreys, L. (1999). Durability of the effects of cognitive-behavioural therapy in the treatment of chronic schizophrenia: 12 month follow-up. British Journal of Psychiatry, 174, 500 504. Other titles in this series 1. Clinical Psychology Services for Children,Young People and their Families 2. Psychological Well-Being for Users of Dementia Services 3. Clinical Psychology Services for People with Learning Disabilities and their Carers 4. Clinical Psychology Services for People with Diabetes Mellitus 5. Clinical Psychology Services for Older People, their Families and Other Carers 6. Using Clinical Psychology Services 7. Clinical Psychology Services for People Affected by HIV/AIDS 8. Clinical Psychology Services to Obstetrics and Gynaecology 9. Clinical Psychology Services for People with Acquired Neurological Disorders and their Carers 10. Clinical Psychology in Adult Services 11. Clinical Psychology in Dentistry 12. Purchasing Clinical Psychology Training 13. Guidelines for Clinical Psychology Services 14. Clinical Psychology in Substance Misuse 15. Clinical Psychology Services in Primary Care 16. Clinical Psychology Services to Black and Ethnic People 17. Clinical Psychology Services in HIV and Sexual Health 5

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