1. CBT for Inpatient and Crisis Settings: A Newly Developed CBT Approach to Enable the Individual to Make Sense Of Crisis, and Enhance the Milieu Isabel Clarke and Hannah Wilson Clinical Psychologists AMH Woodhaven.

2. The case against acute phase individual CBT Admissions are too short and unpredictable to deliver NICE guideline adherent, diagnosis linked, treatments People too disturbed and fragile; for instance, for exploring trauma history – might destabilise Better wait to refer to Psychological Therapies on discharge

3. The Case for Acute phase CBT Crisis is the time when people most need to make sense of what is happening to them - To make sense in a way that leads to the individual taking control – a way out of the revolving door. Crisis as a window of opportunity – ‘the turning point’ in Recovery terms. Unbearable emotion as the simple heart of complex problems – identify ways forward that the team can deliver (nurse led group work, practical help from community teams etc.) A basis for spreading psychological thinking throughout the staff group.

4. A CBT Approach for Inpatient and Crisis Work Cross diagnostic Suitable for working with high states of arousal – identifies feeling awful inside and the individual’s relationship to this feeling as the problem. Effective over one, two or three sessions (evaluated – see Durrant et al). Introduces approaches to change that can be supported by staff on the ward, and carried on by CPN etc. in the community after discharge.

5. “Third Wave” – term coined by Hayes (Acceptance & Commitment Therapy) Kabat-Zinn. Applied mindfulness to stress and pain. Segal, Teasdale & Williams. Mindfulness Based Cognitive Therapy (relapse in depression.) Linehan. Dialectical Behaviour Therapy (BPD) Chadwick. Mindfulness groups for voices. Hayes

6. “Third Wave” Cognitive Therapies Developments in CBT as it tackles personality disorder, psychosis etc. Therapeutic relationship important Past history is significant Change lies not so much in altering thought to alter feeling, but in altering the person’s relationship to both thought and feeling Mindfulness is a key component.

7. Applying CBT to Severe Mental Health Problems. 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

8. LEVELS OF PROCESSING – A THEORETICAL JUNGLE! The cool reflection problem leads to the recognition of different types or levels of processing within CBT e.g.s of theories of this. Ellis: Inference and Evaluation –Hot and Cold cognition Power & Dalgleish. SPAARS (theory of emotion). Mark Williams: overgeneral autobiographical memory. Metacognition. Wells & Mathews. S-REF –. 'Vulnerability to psychological dysfunction is associated with a cognitive-attentional syndrome characterised by heightened self- focussed attention, attentional bias,ruminative processing and activation of dysfunctional beliefs....mediated by executive processes that are directed by the patient's beliefs'. Brewin’s VAMS and SAMS (just memory). Ehlers & Clark (following Roediger): conceptual v.data driven processing.

9. Features the theories have in common. There is one direct, sensory driven, type of processing and a more elaborate and conceptual one. The same distinction can be found in the memory. Direct processing is emotional and characteristed by high arousal. This is the one that causes problems – e.g. flashbacks in PTSD.

10. Features of Emotion Driven Processing 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 (cf. Brewin’s PTSD research) Role of past trauma in psychosis and PD is now being properly recognised.

11. Ideas to think about Symptoms are just different ways of escaping from or avoiding unpleasant emotions – what examples can you find? In the light of this way of looking at things, what should be the main goals of therapy? To meet those goals, where does CBT need to direct its efforts? What therapeutic methods are likely to be useful? What becomes less important?

12. Linehan’s STATES OF MIND (from Dialectical Behaviour Therapy) – Maps onto Interacting Cognitive Subsystems EMOTION MIND (Implicational subsystem) REASONABLE MIND (Propositional Subsystem) WISE MIND IN THE PRESENT IN CONTROL

13. The ‘horrible feeling’ Human beings need to feel physically safe and OK about themselves Emotion Mind/Implicational Subsystem produces a sense of threat when those conditions are not met Emotion Mind/Implicational memory presents past events as present (trauma) People develop ingenious ways of avoiding facing the sense of threat

14. WAYS OF COPING WITH FEELINGS WHERE THREAT TO SELF IS TOO GREAT 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 appraisal – psychosis

15. Linehan’s STATES OF MIND (from Dialectical Behaviour Therapy) – Maps onto Interacting Cognitive Subsystems EMOTION MIND (Implicational subsystem) REASONABLE MIND (Propositional Subsystem) WISE MIND IN THE PRESENT IN CONTROL

16. Figure 1. Typical Formulation FEAR RAGE SADNESS PAST ABUSE LOSSES PARTNER LEAVING CUT SELF ATTEMPT SUICIDE FRIENDS & FAMILY ALARMED. COULD LOSE CUSTODY OF CHILDREN FEEL WORSE NIGHTMARES CAN’T SLEEP MORE DIFFICULT TO COPE AVOID GOING OUT:SEEING PEOPLE MORE TIME TO BROOD

17. Psychosis formulation Fear Sense of threat The past Being in crowds, busy places Intrusive thoughts This means I’m bad and others want to hurt me Withdraw, hide away Or Fight, becomes aggressive Escapes from thoughts By slipping into unshared world Hears voices This also means I’m bad and others want to hurt me Tense, sweaty, heart races

18. The Individual Therapy Approach  The key features of the Woodhaven therapeutic approach are as follows:  Simple formulation based on relationship to emotion, informed by the ICS split between the emotional and logical systems. (Interacting Cognitive Subsystems: see Teasdale & Barnard 1993)  A “Third Wave” Cognitive therapy – focus on intervening between thought and feeling rather than altering thought to effect feeling (see Hayes et al. 1999)  Management of arousal (breathing control), and mindfulness training to facilitate intervention in the cognitive/emotional process.

19. The Individual Therapy Approach cont.  Techniques of meeting, expressing and letting go of emotion as opposed to the previous avoidance.  This draws on Linehan's (1993) approach and has similarities to Emotion Focused Therapy (Greenberg 2002).  Practical discussion of lifestyle management to ensure the continuation of a better adjustment.  All these features are designed to enable someone to take control of their own recovery – in sympathy with the Recovery Approach (e.g. Repper & Perkins, 2003).

20. Providing a cognitive science based theoretical context. Interacting Cognitive Subsystems Evolutionary approaches - Gilbert etc. Attachment theory - Bowlby etc. Cognitive Analytic Therapy. Current approaches to CBT for personality disorders: Schema focussed approaches Dialectical Behaviour Therapy (Linehan) ACT.

21. Features of Interacting Cognitive Subsystems There are 9 subsystems, each with its own type of coding. Some deal with sensory perception - auditory and visual Some deal with language processing There are two higher order systems: the propositional and the implicational.

22. Body State subsystem Auditory ss. Visual ss. Interacting Cognitive Subsystems. Implicational subsystem Implicational Memory Propositional subsystem Propositional Memory Verbal ss.

23. The Propositional Subsystem Verbal coding. Manages logical thought - “cool cognition” Verbally coded memory store integral to the subsystem. Communicates directly only with the other language subsystems. Intercommunication between it and the implicational subsystem = “Central Engine of Cognition.”

24. Implicational Subsystem Coded in all modalities - memory and current processing Concerned with meaning and significance Information about threat and value Particularly concerned with the status of the self. Directly connected to sensory and body subsystems

25. A challenging model of the mind. The mind is simultaneously individual, and reaches beyond the individual, when the implicational ss. is dominant. This happens at high and at low arousal. There is no boss system – only a constant balancing act between logic and emotion – human fallibility Mindfulness is a useful technique to manage that balance.

26. Important Features of this model Our subjective experience is the result of two higher order processing systems interacting – neither is in overall control. Each has a different character, corresponding to “hot” and “cool” cognition. The IMPLICATIONAL Subsystem manages emotion – and therefore relationship. The verbal, logical, PROPOSITIONAL ss. gives us our sense of individual self.

27. Taking Experience Seriously in Psychosis Psychosis: when Emotion Mind/Implicational does not mesh properly with Reasonable Mind/Propositional This leads to a different quality of experience – fine in the short term – a problem when stuck Normalising the difference as well as the continuity – shared and unshared reality Sensitivity and openness to anomalous experience – continuum with normality Understanding the role of emotion – the feeling is real; the ‘story’ is improbable

28. Evidence for a new normalisation Schizotypy – a dimension of experience: Gordon Claridge. Mike Jackson’s research on the overlap between psychotic and spiritual experience. Emmanuelle Peter’s research on New Religious Movements. Caroline Brett’s research: having a context for anomalous experiences makes the difference between – whether they result in diagnosable mental health difficulties – whether the anomalies/symptoms are short lived or persist. Wider sources of evidence – e.g.Cross cultural perspectives; anthropology. Richard Warner: Recovery from Schizophrenia.

29. The Everyday The Transliminal Ordinary Clear limits Access to full memory and learning Precise meanings available Separation between people Clear sense of self Emotions moderated and grounded A logic of ‘Either/Or Numinous Unbounded Access to propositional knowledge/memory is patchy Suffused with meaning or meaningless Self: lost in the whole or supremely important Emotions: swing between extremes or absent A logic of ‘Both/And ’

30. The Next step The formulation shows what is going wrong – and how it remains stuck The formulation becomes the guide for exploring ways forward

31. FEAR RAGE SADNESS Cut self Attempt suicide Friends and family alarmed. Could lose custody of children. Feel worse Nightmares: can’t sleep More difficult to cope Avoid going out and seeing people More time to brood PAST ABUSE LOSSES PARTNER LEAVING WAYS FORWARD Don’t let the feelings be in control: YOU ARE IN CHARGE Do things despite the feeling Breathing and mindfulness to get back to the present Use the energy of the anger positively Typical formulation

32. Psychological Group Programmes. (complement the individual work) Dialectical Behaviour Therapy based Emotional Coping Skills Group – 6 session rolling programme. The Making Friends with Yourself Group This is a 3 session Self Esteem Programme Based on ‘Compassionate Mind’ approach The What is Real and What is Not Group 4 session psychosis (voices and other symptoms) programme Based on the idea of normalising anomalous experiences and so reducing stigma ‘Your Safety System; a users’ guide’. Manual based arousal management programme for delivery by nursing staff following training.

33. Working with Psychosis using this Model Managing arousal – Reasonable Mind/Propositional is less accessible at both high and low arousal Validate the experience Validate the emotion Persuasion to join “shared reality” “Sensitivity” – normalisation based on Claridge’s work on schizotypy.

34. Session 2. The role of Arousal shaded area = anomalous experience/symptoms are more accessible. Level of Arousal Ordinary, alert, concentrated, state of arousal. Low arousal: hypnagogic; attention drifting etc. High Arousal - stress

35. Linehan’s STATES OF MIND applied to PSYCHOSIS Discussion of Ways of coping suggested by this approach – management of arousal and distraction.

36. Working with the Institution.  Service users in crisis have a need to ‘make sense’.  Staff also need to ‘make sense’.  Reflection in the face of crisis and risk needs the skills of psychological thinking. The Psychological Therapist can support, develop and inform this psychological thinking.  In Woodhaven, this is achieved by:  Joint psychological assessment with key-worker.  Supervision of joint psychological work.

37. Further working with the Institution  Weekly Reflective Practice Groups for each ward, for the nursing staff, facilitated by a psychologist.  Co-facilitated, multi-disciplinary group work with a psychological focus.  Psychology-led training for staff group on developing strengths based care planning for the most challenging clients.  Training has lead to request for regular multi- disciplinary care planning meetings (to be implemented)

38. Training Issues 1. Practical issues –Whole-unit staff training 2.Issues of scepticism –Psychological training in a medic-led environment 3. Issues of attitude –Ownership of the training – (Hastings & Remington, 1995) 4. Issues of staff well-being –Impact of the nature of the work – (i.e. protection from burn out)

39. Issues of Scepticism Introduction to evidence-based psychological approaches. Recognise the strengths and diversity within the team as well as working towards a consistent, Recovery oriented, approach. Promote development of positive care plans for challenging behaviour using these approaches. –Teaching given on behaviour principles of behaviours to increase, rewards and reinforcements vs. behaviours to decrease and punishment Be able to conceptualise challenging behaviours in helpful ways.

40. Issues of attitude and ownership Staff ownership of the training to improve application of the approach once training complete Before the training, allocated into teams of 5 and asked to bring a current case to discuss Small group work to formulate the case they brought, develop a positive care plan with clear triggers, reinforcements and integrated opportunity for desired change based on teaching received Two days spread out over two weeks –Try out the approach in the ward environment, record the results, and….. –Be able to report back on and discuss the experience at the second day.

41. Outcomes Staff valued opportunity to think Reduction in challenging behaviours in some cases presented Concept of focusing on behaviours to increase as opposed to behaviours to decrease established in the unit Regular MDT care planning and case discussion requested by staff

42. Exercise Identify the training needs of the unit you work in What opportunities are there to deliver this? What obstacles are there? How can you ensure the training has lasting impact?

43. Principles behind design of the evaluation.  Designed to measure the intervention described above.  Measurement of symptom change not useful for evaluation because of concurrent interventions (medication etc.).  Self efficacy and management of emotions are the aims of the intervention, hence they are evaluated.  Measurement of individual Goal achievement.

44. Measures 1. CORE - to measure level of psychopathology rather than change. 2. Mental Health Confidence Scale (MHCS) (Carpinello, Knight, Markowitz & Pease, 2000) 3. Locus of Control of Behaviour Scale (LCB) (Craig, Franklin & Andrews, 1984) 4.Goal Setting: Visual-analogue, ideographic, measure of individual goals. 5. Living with Emotions -designed for this research. Three questions looking at confidence in coping with emotions. Each question is scored on a Likert scale

45. Mental Health Confidence Scale Pre Post

46. Pre Post Locus of Control

47. Pre Post Living With My Emotions

48. Pre Post Goal Setting Questionnaire Client’s perception of how close they were to reaching their goals **

49. Results Pre and post therapy scores suggest that service users felt:  more able to cope with their mental health difficulties  had a greater internal sense of control  felt more confident in dealing with their emotions  felt more confident in employing strategies to deal with strong emotions.

50. SUMMARY AND CONCLUSIONS 1. Psychological services can contribute to developing a therapeutic milieu in an in-patient acute setting in a number of ways: staff support and training reflective practice, on-going supervision, group and individual therapy 2. Service users report increased confidence and coping after very brief psychological therapy

51. Contact Details and References Isabel.Clarke@hantspt-sw.nhs.uk Hannah.Wilson@hantspt-sw.nhs.uk Durrant, C., Clarke, I., Tolland, A. & Wilson, H. Designing a CBT Service for an Acute In-patient Setting:A pilot evaluation study. Clinical Psychology and Psychotherapy. 14, 117-125. Cognitive Behaviour Therapy for Acute Inpatient Mental Health Units; working with clients, staff and the milieu. Edited by Isabel Clarke & Hannah Wilson. Routledge. June 2008 Isabel’s website: www.scispirit.com/psychology