Comprehend, cope & connect an update and survey Isabel Clarke Consultant Clinical Psychologist

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

Comprehend, cope & connect Transforming acute and community mh Comprehend, cope & connect Transforming acute and community mh. 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

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

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

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

Skills groups – eg. Emotional Coping Skills Comprehend, cope & connect Psychological skills development = the treatment Whole staff team involved in teaching, coaching or supporting these skills Skills groups – eg. Emotional Coping Skills Psychotic Symptom Management Daily Mindfulness on the ward Staff offer skills coaching where needed

Comprehend, cope & connect Working across the care pathway and beyond. Skills groups can be accessed by inpatients or in the community Formulation informs care across the pathway Where acute sevices have introduced the approach, community services often follow.

Comprehend, cope & connect The theory behind the approach

REASONABLE EMOTION MIND MIND Comprehend, cope & connect- theory Different Circuits in the Brain (Adapted from DBT) REASONABLE MIND EMOTION MIND WISE MIND Reasonable Mind Memory Emotion Mind Memory Though L does not refer to it specifically, the ICS split maps onto the basic DBT model of the mind, as follows: The idea of a shifting balance is central to DBT, so that the self is seen as moving between the minds. Wise mind is the same as the two central ss. in ICS working smoothly together; reasonable mind dominance suggests an avoidance of the emotional (because the physical state of arousal produced by memories is anticipated as too unpleasant). Emotional Mind is where the implicational is dominant, and a loop can be set up that excludes current reflection, and so revision of past patterns – whether of depressive rumination or impulsive action. IN THE PRESENT IN CONTROL 10

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

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

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”

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 . Some Southern Health community services. Surrey & Borders Partnership NHS Foundation Trust Sheffield Health and Social Care Foundation Trust NHS Lothian (Edinburgh) – all Acute. Huddersfield, Harrogate & Dewsbury Community and Acute..

Comprehend, cope & connect

Evaluating the Programme: 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.

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.

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 – up as well as down attention – i.e. mindfulness emotions – expression as part of management Facing the past (without revisiting it) – building a healthy relationship with it Positive anger work

Comprehend, cope & connect in italk 6 groups on relationship Relationship with self - self compassion Developing the internal good friend – both the encouraging friend and the honest friend Relationship s with others. Balancing priorities Putting self in others shoes while avoiding getting sucked in Managing intimacy Internal relationship with different parts of the self Recognizing the value and downside of each Developing a mindful centre

DRAWING ON THE DIFFERENT ASPECTS OF THE SELF An example BACKWARDS X – keeping the same is safer UNIVERSAL CARER Empathic. Willing to help everyone Keeps me locked in the past   Taken advantage of. Own needs neglected YOU Going forward Mindfully. Able to draw on the best of all the aspects of yourself OBEDIENT PERFECTIONIST Conscientious, effective. Achieves THE REBEL.Wants to live life to the full – accepts me as I am Puts me in risky situations - bad for self respect Never good enough. Self Critical, so avoids trying anything

Comprehend, cope & connect in italk Use of Mindfulness Mindfulness is used throughout as a tool to work on change. Important mindfulnesses: Of emotion – deconstructed as a physical event Of self compassion Of your strong centre Work in progress: 7 full programmes completed in 3 areas of Hampshire. 4 further programmes in preparation. 4th area about to come on stream

Evaluation: CASE SERIES Sessions PHQ9 start PHQ9 end Change GAD7 start GAD7 end 20 13 4 -9 17 7 -10 12 21 8 -13 18 -2 5 3 -15 10 1 25 -7

Comprehend, cope & connect and culture free therapy A new initiative in the planning stages.

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