1. Therapeutic Alliance with the whole team
Isabel Clarke
Consultant Clinical Psychologist

2. 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

3. 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

4. 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

5. 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.

6. 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

7. 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?

8. 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.

9. 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

10. Contact details, References and Web addresses
Araci, D & Clarke, I (2016): Investigating the efficacy of a whole team, psychologically informed, acute mental health service approach, Journal of Mental Health, DOI: /
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,