Therapeutic Alliance with the whole team Isabel Clarke Consultant Clinical Psychologist

The gap between the team and the therapist Psychological approach Listens Makes sense – formulates Collaborative Holds hope and strengths Challenges – facing feelings Changing behaviour patterns Team Medical approach Diagnosis Risk assessment Patient = passive recipient Focus on pathology Treatment to eliminate suffering Behaviour change should follow. Legal controls if it doesn’t

Tensions between therapist and team Good cop/bad cop (can go either way) Therapist ‘upsetting’ patient, increasing risk Medication or ECT interfering with therapy Symptom elimination v quality of life – Recovery goals Therapist doing mysterious things. Team feel disempowered. Apparent ineffectiveness of therapy cf. rapid effects of medication

Time for a holistic approach Both service users and medical staff want to move beyond the purely medical. Recovery Need to extend the collaborative, therapeutic approach to the team Preserve accurate empathy Strip away assumptions Factor in trauma

Aims To give the service user in crisis the following hopeful Recovery message: Their distress is understandable and taken seriously Their central role in making things change is demonstrated. To teach new ways of coping and support the use of these skills. To enable all staff to work with the psychological model, through training, supervision and support from the therapy service.

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 6

Ideas to think about When something has gone wrong, each one of us will experience a horrible feeling. How do you deal with a horrible feeling? What do you feel like doing about it? What do you actually do? If the feeling was there all the time, and you kept reacting to it like that……..what would happen? What might this say about symptoms?

Based Formulation Template (Comprehend, Cope and Connect) Emotion and Behaviour Based Formulation Template (Comprehend, Cope and Connect) 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.

Skills teaching and coaching – a team response Staff trained, supported and supervised to deliver basic psychological strategies to break the cycles Programme of psychologically informed group work. Regular mindfulness sessions. Individual coaching on the ward or by Hospital at Home staff. Including carers, partners etc. where relevant

Contact details, References and Web addresses Isabel.Clarke@southernhealth.nhs.uk: isabel@scispirit.com Araci, D & Clarke, I (2016): Investigating the efficacy of a whole team, psychologically informed, acute mental health service approach, Journal of Mental Health, DOI: 10.3109/09638237.2016.1139065 Clarke, I. (Ed.) (2010) Psychosis and Spirituality: consolidating the new paradigm. Chichester: Wiley Clarke, I. ( 2008) Madness, Mystery and the Survival of God. Winchester:'O'Books. 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