Psychology Formulation Based Staff Training Surehaven Hospital Dr Marie-Louise Holmes Clinical Psychologist

Surehaven Hospital Shaw Healthcare Opened in Drumchapel 2010 17 bed low secure psychiatric hospital Patients detained under the Mental Health Act and requiring a secure care environment Range of presentations, psychosis, personality difficulties, learning disabilities, brain injury Two wards, male and female MDT – Hospital managers, consultant psychiatrist, occupational therapist, clinical psychologist, nursing team and healthcare assistants.

Training Rationale 1. To empower the ward based staff in relation to the use of empathic containment of patient distress. 2. To enhance staff understanding of patient behaviour from a psychological perspective 3. To equip staff with skills necessary to support individual psychological therapeutic work 4. To capitalise on the high level of enthusiasm and dedication to patient care that existed within a newly recruited staff team 5. To provide a rich learning opportunity aimed at increasing insight and empathy rather than simply information provision

Forensic Psychology Matrix Guidance Therapeutic Milieu Training ‘All front line clinical staff should be made aware of the particular difficulties of working with psychiatric in-patients with forensic needs, and the underlying reasons for challenging behaviours.’ ‘They should be given training in basic psychological models and advised of the aims of the psychological interventions available with the service so that they can reinforce the skills patients learn in psychological treatment.’ ‘Special attention should be given to equipping staff with the skills necessary to feel confident in supporting the emotional and mental health needs of service users.’

Psychological Formulation A hypothesis about service users difficulties based on psychological principles and theories The assumption is that this process will render even the most unusual or disturbing behaviour and experiences understandable: ‘At some level it all makes sense’ (Butler, 1998)

Key Elements of Training Design Training needs analysis carried out Particular service users difficulties considered Psychological interventions already underway MDT reflection on areas for development Training made mandatory for all staff

Initial Topics Identified Understanding and Responding to – Personality Difficulties Psychosis Suicidal Behaviour Self Harm Introduction to – Compassionate Mind Therapy for Trauma Counselling Skills Training

Style of Delivery Opportunity to model warm, empathic and containing therapeutic style Small numbers facilitate interactive workshop dynamic rather than lecturing style Emphasis on collaboration and eliciting existing knowledge from the audience Safe space for non-judgemental exploration of reality of working with complex presentations

Content and Structure Participants identify what they wish to gain from the day Structure is flexible with interactive discussion tailored to needs of the particular group Education / Theory section – interactive, elicit existing knowledge and combine with theory Video clips or practical exercises to reinforce theoretical understanding Case study – Participants develop basic formulation and devise intervention Skills practice Reflective consolidation of main learning outcomes Feedback and further resources

Example Session Personality Difficulties Aim to increase insight and empathy Assumption that this will reduce staff counter-transference reactions

Personality Difficulties Training Before session staff asked to write down words that come to mind in relation to ‘Personality Disorder’ – Obsessional, Manipulative Impatient Difficult to manage, burn out Frustration Helpless Heart sink Dependent Emotional, self harming No reasoning, anxious, narcissistic, controlling

Main focus of the day – Psychological understanding based on concept of Early Maladaptive Schemas (Young 2003) Developmental psychology perspective firmly rooted in Attachment Theory De-stigmatising approach Extreme personality traits – result of genetic temperament and unmet needs arising from attachment difficulties in childhood.

After session participants repeated exercise – Lonely Abandoned Self loathing Treatable Vulnerable ‘The behaviour is not about me’ (the healthcare professional) Emotional needs unmet ‘..didn’t choose their genetics or environment..’ ‘Still emotionally a child’ Difficulty communicating Misunderstood Clear shift in the themes being expressed

Compassionate Mind Therapy for Trauma Key approach used at Surehaven in the treatment of patients with chronic interpersonal trauma histories Mechanism of change is teaching patient to emotionally relate to self with compassion and understanding rather than self loathing and blame This undermines process which maintains suicidal feelings and emotional attacks on the self

Participants engaged in experiential therapeutic exercises Reflection on their own level of self criticism Writing a compassionate letter to themselves This proved useful in terms of both personal and professional development Staff were better able to support psychological intervention using this approach by encouraging patient to use self compassion as a response to distress rather than self criticism

Feedback / Audit Feedback from all sessions very positive Likert scale ratings all either agree / strongly agree – Theory was clearly explained Practical exercises enhanced learning experience Delivery style tailored to meet needs of the group Able to apply knowledge / skills in your role

Qualitative Feedback Staff responses indicate Increased empathy for patient difficulties Increased insight into psychological factors influencing presentation Improved confidence in therapeutic relationship building Increased confidence in responding to distress Improved understanding of psychological interventions Increased recognition of own skills More realistic expectations of self and patients

Patient responses included – ‘Staff are better equipped to help me and speak about my problems’ ‘The enthusiasm from all the staff has been great’ ‘Its great that nursing staff can follow up my psychology work with me’