Clinical Psychology - Lecture 6

Front 1

Rankin & Regan (2004)

Back 1

- Define 'complex needs' as:
- Breadth: multiple needs that are interrelated
- Depth of Need: profound, severe, serious or intense needs
- Refers to an active framework for response
- "Each individual with complex needs has a unique interaction between their health and social care needs and requires personalised response from services"

Front 2

Secondary Care

Back 2

- Deals with severe, enduring and complex mental health problems
- Requires referral
- Community Mental Health Team care coordination
- In-patient care
- Rehabilitation and residential services

Front 3

Referrals to Secondary Care

Back 3

- Suicide risk or harm to others
- Disability because of mental health
- GP requires expertise from secondary care for diagnosis or treatment
- Therapeutic relationship with patient broken down
- Primary care intervention options exhausted
- Particular psychotropic medication required
- Patient requests

Front 4

Killaspy et al. (2000)

Back 4

- Most new referrals to psychiatric out-patient clinics have a diagnosis of common mental health problems (e.g. depression, anxiety)
- 90% of follow-up patients have diagnoses of complex and enduring mental health problems (e.g. schizophrenia, bipolar)
- Not usually referred directly by GP, seen as follow-ups after in-patient admission
- Out-patients changed from triage for admission towards assessment of less severe conditions and follow-up

Front 5

Disorders Seen in Secondary Care

Back 5

- Psychosis (e.g. schizophrenia, schizoaffective disorder)
- Bipolar disorder
- When risk is present:
- Personality disorders
- PTSD
- Chronic depression
- OCD

Front 6

Definition of Mental Disorder

Back 6

- Clinically significant behavioural or psychological pattern that occurs in an individual and causes distress or disability
- Not an expectable and culturally sanctioned response to event (death of loved one)

Front 7

Birchwood (2010)

Back 7

- Severity of psychotic experiences is an imperfect predictor of distress and behaviour linked to symptoms

Front 8

Role of Clinical Psychologists

Back 8

- Assess, formulate, treat wide range of problems across age and disability range within secondary care
- Direct work with clients and their families
- Indirect work through staff, staff teams, organisations
- Provide training and supervision
- Evaluate interventions, research
- Manage services
- Provide clinical leadership to teams

Front 9

Mediating Psychological Processes

Back 9

- Psychological processes mediate the impact of familial risk (biological), social circumstances and life events on mental health
- Kinderman, Schwannauer, Pontin, & Tai (2013)
- Psychological interventions can have a positive effect on mediating processes

Front 10

Kendell (1988)

Back 10

- Diagnosis of mental health disorder does not predict what treatments will be effective or response to medication

Front 11

Heather (1976)

Back 11

- Diagnosis of mental health disorder does not predict what treatment people will receive

Front 12

Problem With Symptoms

Back 12

- Many people with symptoms are not in treatment and functioning adequately
- Symptom change is only slightly related to client ratings of symptom change and satisfaction with treatment
- Few patients come to treatment because of high scores on a psychological measure
- Kazdin (2001)

Front 13

Problems With Questionnaires

Back 13

- Only tell us about symptoms (e.g. Becks Depression Inventory: I am sad all the time)
- But never asks the patient how bothered they are about symptoms and why

Front 14

Short-Term Problems

Back 14

- Someone might feel bad about themselves and take drugs to alleviate distress
- Realising this doesn't help they turn to healthy alternative strategies such as listening to friends and problem-solving

Front 15

Longer-Term Problems

Back 15

- Someone might feel bad about themselves and take drugs to alleviate distress
- They have fewer alternative strategies available and the alternatives are problematic (e.g. rumination)
- Persists in using arbitrary control (e.g. drug taking) despite consequences

Front 16

Fadden et al. (2004)

Back 16

- Clinical psychology can provide a distinct perspective from the traditional view of mental disorders being biological

Front 17

May (2004)

Back 17

- Traditional view of mental disorders (being biological) is often not helpful
- Clinical psychologist view may be more helpful

Front 18

Individualised Formulations

Back 18

- Specific to the client, more person centred, better than diagnosis
- Should predominate clinical planning in early intervention
- Embrace diagnostic uncertainty
- Incorporates diversity and difference (gender, race, culture)

Front 19

Service User Involvement

Back 19

- Clients perspectives essential to understanding mental health problems and how to approach interventions
- Interventions specifically tailored to individual need, increase clients choice of treatment
- Facilitating capacity to choose through alternative communication methods

Front 20

Humanistic Counselling

Back 20

- Client-centred way of helping people to see things more clearly, from different perspective
- Not directive or giving advice
- Not much research for problems such as psychosis
- Not really recommended by NICE for secondary service

Front 21

Psychoanalytic Therapies

Back 21

- Conflict arises from early experiences being re-enacted, unconscious
- Resolved through relationship with therapist, longer-term
- Less research compared to CBT, so not used often in secondary care
- Tends to be offered more for problems related to personality/relationship issues (e.g. borderline)

Front 22

Matusiewicz et al. (2010)

Back 22

- Meta-analysis, CBT is an effective treatment for personality disorders

Front 23

Jones (2004)

Back 23

- CBT as treatment for bi-polar, effects are modest

Front 24

Wykes et al. (2008)

Back 24

- Meta-analysis, CBT and psychosis
- Mean effect size: 0.4 (medium to large)

Front 25

Who Does CBT For Psychosis Work For?

Back 25

- Prodromal (early stages of emerging episode)
- 1st/2nd episode
- Acute psychosis
- People at risk of relapse
- Treatment resistant
- Older patients
- Dual diagnosis
- Forensic/violence
- Command hallucinations

Front 26

Morrison (1998)

Back 26

- Voices Model
- CBT formulation for psychosis (5-factor model)
- Trigger leads to hearing voices, patient interprets meaning of voices, acts in unhelpful ways, affects mood and arousal
- Viscous circle
- Intervene somewhere in the circle, perhaps using behavioural experiments to challenge interpretations

Front 27

Formulation for Psychosis

Back 27

- Can't always persuade people that their delusions are wrong, may be filling a hole in their life
- Understandability of psychotic symptoms (content, development, maintenance) has implications for change
- If understanding can be reached, patient will become more active in change process

Front 28

Key Aim of Mental Health Services

Back 28

- Recognising factors that indicate a person poses risk to themselves or others or from others
- Developing strategies to minimise risk
- Exploring features of difficult to manage situations, developing strategies
- Reviewing risk factors for suicide
- Sharing skills that work

Front 29

Mental Health Patient Risk to Others

Back 29

- Vast majority of violent people do not have mental health problems
- 1 in 5 people have a history of mental health problems, yet only 9% of homicides are perpetrated by someone with a history of mental health problems
- 90% of people with a diagnosis are not violent

Front 30

Risk Factors For Violence

Back 30

- Substance abuse
- History
- Young
- Male
- Socio-economic disadvantage
- Antisocial personality disorder
- Psychotic symptoms (paranoia)
- Diagnosis of childhood/adolescent problem or learning disability

Front 31

Steadman & Mulvey (1998)

Back 31

- People recently discharged from hospital due to mental health difficulties are no more dangerous than the general population
- Difficult to predict risks

Front 32

Circumstances That Increase Risk of Violence

Back 32

- Chaotic and violent family background
- Ongoing conflict with family members
- Controlling atmosphere
- Attitudes of others (i.e. Doctor)
- Little awareness of problems
- Beliefs increasing feeling of threat (paranoia)

Front 33

Minimising Risk of Violence

Back 33

- Form good relationships and engagement
- Figure out what's important to individual and avoid interfering with their control of that
- Talk openly about feelings such as anger
- Try to see things from their perspective
- Minimise patients perceived threat
- Get good supervision