1. COMPREHEND, COPE & CONNECT GETTING TO THE SIMPLE HEART OF THE COMPLEX PROBLEM NEW WAYS TO BRING CBT TO ACUTE SERVICES, IAPT CHALLENGES AND BEYOND ISABEL CLARKE CONSULTANT CLINICAL PSYCHOLOGIST

2. COMPREHEND, COPE & CONNECT THIS APPROACH GETS AWAY FROM LABELS AND STIGMA BY: Meeting people where they are – hearing their distress Understanding what they do to manage it – for example:  Self harm  Attempting suicide  Withdrawing from life etc. And offers different ways to manage distress

3. COMPREHEND, COPE & CONNECT TRANSFORMING ACUTE SERVICES A practical way of introducing whole team psychological working A formulation – way of understanding their problems worked out with the individual Shared with the team Informing psychological approaches that the whole team can deliver

4. Comprehend, cope & connect The Formulation Try to escape from the emotion by avoidance, self harm etc. Feel better short term Bad longer term consequences. Aversive emotion worse. Past: abuse, trauma etc. Recent triggering event Another maintaining cycle feeding the emotion Horrible Feeling Wider protective factors - family, beliefs etc

5. COMPREHEND, COPE & CONNECT THERAPEUTIC APPROACHES  Mindfulness  Grounding in the body and the present – where the individual can be in control  Arousal management  Emotion regulation skills to face the emotion  Psychosis: Unshared reality as an escape from emotion

6. COMPREHEND, COPE & CONNECT THERAPEUTIC APPROACHES CONTINUED The Compassionate Friend Programme Treat yourself as you would a good friend Emotional Coping Skills Accepting and managing emotions  Encouraging behavioural change  Behaviours to increase  Behaviours to decrease

7. COMPREHEND, COPE & CONNECT PSYCHOLOGICAL SKILLS DEVELOPMENT = THE TREATMENT Whole staff team involved in teaching or supporting these skills  Skills groups – eg. Emotional Coping Skills  Psychotic Symptom Management Daily Mindfulness on the ward Staff offer skills coaching where needed

8. COMPREHEND, COPE & CONNECT WORKING ACROSS THE CARE PATHWAY Skills groups can be accessed by inpatients or in the community Formulation informs care across the pathway

9. COMPREHEND, COPE & CONNECT THE THEORY BEHIND THE APPROACH

10. COMPREHEND, COPE & CONNECT - THEORY DIFFERENT CIRCUITS IN THE BRAIN (ADAPTED FROM DBT) REASONABLE MIND EMOTION MIND IN THE PRESENT IN CONTROL WISE MIND Reasonable Mind Memory Emotion Mind Memory

11. COMPREHEND, COPE & CONNECT - THEORY THE ‘HORRIBLE FEELING’ Human beings need to feel physically safe and OK about themselves Emotion Mind produces a sense of threat when those conditions are not met This signals the body to get ready for action – which in turn focuses the mind on threat Emotion Mind/ Emotion Mind memory presents past events as present (trauma) People develop ingenious ways of avoiding facing the sense of threat

12. COMPREHEND, COPE & CONNECT - THEORY WAYS OF COPING WITH THE HORRIBLE FEELING Giving in - signalling submission (depression) Constant anxiety, worry and hypervigilance Anger - attribute elsewhere. Displacing anxiety – OCD, eating disorder Drink, drugs, etc. Dissociation – flipping between different experiences of the self Cutting out reasonable mind – psychosis

13. COMPREHEND, COPE & CONNECT - THEORY THESE ARE COMMON WAYS OF COPING EARLY TRAUMA/ADVERSITY ADDS TO CURRENT DISTRESS – MAKING COPING MORE DIFFICULT THERE IS NO “THEM AND US” – “ONLY US”

14. COMPREHEND, COPE & CONNECT THE PROGRAMME IN ACTION Piloted in one hospital in Hampshire: 2004 – 2012 (featured in the book: CBT for Inpatient Units – see next slide) Extended to all 4 Acute Services under the Southern Health Trust. in 2012 Also being applied: Surrey & Borders Partnership NHS Foundation Trust Sheffield Health and Social Care Foundation Trust NHS Lothian (Edinburgh)

15. COMPREHEND, COPE & CONNECT

16. Comprehend, cope & connect Evaluating the Programme: Southern Health NHS Foundation Trust 3 papers Quantitative – pre and post measures Published as Araci & Clarke 2016 Qualitative – Staff perceptions of impact on individual, team work and milieu – in submission Qualitative 2 – Service user experiences of the programme - In preparation.

17. Comprehend, cope & connect Study 1 Participants - 46 male, 85 female (N = 131) Mean age of 38.15 (SD = 12.01) 1 Asian British, 1 black British, 84 white British, 1 mixed race white and black Caribbean, 4 white other background, and 3 unstated 35 non-psychotic (mild/moderate/severe), 31 non-psychotic (very severe and complex), 20 psychosis, and 8 organic (cognitive impairment)

18. Comprehend, cope & connect Study 1

19. COMPREHEND, COPE & CONNECT THE COMPREHEND, COPE AND CONNECT APPROACH IN IAPT IAPT has a ca. 50% Recovery rate – what about the other 50%? Southern Health’s italk audited this group and identified that they chracteristically present with: Past issues complicating current coping Long therapy history Relationship/attachment issues. This trans-diagnostic, formulation led, approach is being piloted in italk for those identified with these characteristics.

20. COMPREHEND, COPE & CONNECT IN ITALK 4 Sessions : Listening: formulation: goal setting 6 groups covering skills to break vicious circles identified in the formulation, on managing arousal, attention emotions 6 groups covering skills to break vicious circles identified in the formulation, on managing relationship with self relationship s with others Work in progress!

21. COMPREHEND, COPE & CONNECT AND CULTURE FREE THERAPY A new initiative in the planning stages.

22. COMPREHEND, COPE & CONNECT CONTACT DETAILS, REFERENCES AND WEB ADDRESS  Isabel.Clarke@southernhealth.nhs.uk David Araci & Isabel Clarke (2016): Investigating the efficacy of a whole team, psychologically informed, acute mental health service approach, Journal of MentalHealth, DOI: 10.3109/09638237.2016.1139065 Clarke, I. & Wilson, H.Eds. (2008) Cognitive Behaviour Therapy for Acute Inpatient Mental Health Units; working with clients, staff and the milieu. London: Routledge. Durrant, C., Clarke, I., Tolland, A. & Wilson, H. (2007) Designing a CBT Service for an Acute In-patient Setting: A pilot evaluation study. Clinical Psychology and Psychotherapy. 14, 117-125. www.isabelclarke.org