Clinical skills in the Psychosocial Interventions Pathways Steve Wood Pathways Leader

Clinical guidelines Financial imperatives Clinical guidelines Financial imperatives Cognitive & behavioural models Current skills of mental health nurses Acquisition of skills Our approachCognitive & behavioural models Current skills of mental health nurses Acquisition of skills Our approach Rationale for acquisition of cognitive behavioural skills by mental health nurses

Clinical Guideline 1 December 2002 Developed by the National Collaborating Centre for Mental Health Schizophrenia Core interventions in the treatment and management of schizophrenia in primary and secondary care Psychological treatments – CBT Family work Anxiety

Clinical Guideline 22 December 2004 Developed by the National Collaborating Centre for Mental Health Anxiety Management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care Panic disorder – CBT Self-help based on CBT Generalised anxiety – CBT Self-help based on CBT Depression

Clinical Guideline 23 December 2004 Developed by the National Collaborating Centre for Mental Health Depression Management of depression in primary and secondary care Mild – Self-help based on CBT Problem solving therapy Brief CBT/counselling Moderate to severe – CBT Interpersonal therapy Antidepressants Treatment resistant, recurrent, atypical – Combined CBT/antidepressants PTSD

Post-traumatic stress disorder (PTSD) The management of PTSD in adults and children in primary and secondary care Clinical Guideline 26 March 2005 Developed by the National Collaborating Centre for Mental Health PTSD – Trauma focused CBT Eye Movement Desensitisation & Reprocessing (EMDR) Antidepressant – NOT as first line OCD

Clinical Guideline 31 November 2005 Developed by the National Collaborating Centre for Mental Health Obsessive-compulsive disorder Obsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder OCD & BDD – CBT – individual or group Main menu

RATIONALES FOR SaFF TARGETSSaFF TARGETS 2006/2007 Why bother? Trusts are beginning to be audited in terms of compliance with NICE guidelines and will face financial penalties for failing to comply SaFF targets 14 & 15 Who will carry out all these “psychological” interventions? Main menu

Cognitive model Principles –people’s view of their world is determined by their thinking (cognition) –cognition influences emotions, behaviour and attitudes –impaired/dysfunctional cognition creates mental pathology –significant change in mental disorder needs to involve significant change in cognition Characteristics –treatment involves “collaborative empiricism” –client active participant in assessment e.g. diaries –gives client sense of mastery over feelings thought to be beyond voluntary control –interpretation of thoughts is main determinant of action Behavioural model

Principles –symptoms and behaviour constitute main feature of mental illness –origin and persistence of symptoms of behaviour can be understood through science of learning theory –application of learning theory removes maladaptive symptoms and in so doing cures the disorder Characteristics –person’s behaviour part of own responsibility –treatment aims to extinguish maladaptive conditioned response –behaviour programmes based on functional analysis –non-hierarchical –treatment contracts must be voluntary Medical model

Contrast with medical model … Principles –mental pathology also accompanied by physical pathology –mental illness can be classified as different disorders which each have common features –mental illness is biologically disadvantageous and handicapping –causes of physical and mental pathology in psychiatric illness all explicable in terms of physical illness Characteristics –patient passive recipient of treatment –if patient fails to respond - more powerful treatment or question diagnosis –doctor is expert, chief decision maker and head of the team –“logical” –“scientific ” Main menu

Journal of Advanced Nursing Volume 27 Page February 1998 doi: /j xVolume 27 Issue 2 The clinical skills of community psychiatric nurses working with patients who have severe and enduring mental health problems: an empirical analysis Sheila M. Devane DClin Psychol, Gillian Haddock PhD, Stuart Lancashire MSc, Ian Baguley RMN, Tony Butterworth PhD, Nicholas Tarrier PhD, Abigail James BSc & Phillip Molyneux MSc Abstract This study describes the use of reliable scales to rate the clinical skills of mental health nurses when working with individuals and families with severe mental health problems. The Cognitive Therapy Scale and the Schizophrenia Family Work Scale were adapted for the study and were shown to have good inter-rater reliability when assessing audio-taped interviews carried out by mental health nurses during their usual course of work with patients with severe mental health problems and their families. The sample of mental health nurses studied were shown to have significantly better general therapy skills than specific cognitive therapy technical skills. The implications for training are discussed. Significant difference between general and technical skills Good on understanding, empathy and professional manner Moderate on questioning Poor on specific cognitive behavioural skills –pacing and use of time –collaboration –guided discovery –agenda setting Very poor on –feedback –conceptualising problem –setting goals –implementing goals –negotiating homework Do nurses have the skills? Main menu

How are skills acquired? Nature of “skill” How skills are learnt Micro-skills Combining micro-skills Stages of skills acquisition Main menu

Our approach 4 stages 1.Priming 2.Building confidence/allaying anxiety 3.Enhancing skills 4.Real-life practice Feedback Questioning Main menu