Introduction
- Highgate Mental Health Centre (location of meeting and workplace of Dr. Hanna) was build 4 years ago.
- Wards from Whittington Hospital which had 25 beds per ward were moved to a more appropriate location.
Role of psychologist on acute wards:
- In a survey a few years ago only 17% of ward managers could name a dedicated Clinical Psychologist (CP) (keeping in mind that naming one did not mean that CP did extensive work on the ward).
- CP in Community Mental Health Teams (CMHTs), in an unwritten but generally upheld agreement, allocate 10% of their time to their sector ward – this would be reasonable to do assessments etc., but is difficult to achieve especially for those working part-time.
Work as a CP on an acute ward
- At Highgate Mental Health Centre 1 ½ psychologists work across 5 acute wards.
- Initial plan was to allocate each CP to different wards but it was felt that it was better to work together across all wards to make both a male and female CP available for all service users.
- Referrals of patients to the CPs are done by ward staff and collected twice weekly.
- A wide range of people are referred (personality disorder, psychosis, depression, OCD, eating distress, suicidal), many of them under section of the Mental Health Act.
- They are assessed within a week or two and then a report is written. The aim is to develop a formulation derived from both their life-history and from theory.
- This is then shared with the team (which generally involves more people than for a CP working in a CMHT) on a need-to-know basis, this includes the Consultant Psychiatrist, GP, Primary Nurse and Care Co-ordinator – all along confidentiality/privacy is considered especially when involving traumas and personal information.
- Therapy sessions are offered on a weekly basis and take place on the wards. Sessions are planned a week in advance and last for 1 hour but can be split in two ½ hour sessions.
- Therapy is not primarily aimed at symptom resolution or character change, but that can happen. The main aims are early and safe discharge, resolution of acute distress and optimising social inclusion opportunities. The latter is often an important point because social networks are often impoverished when leaving hospital, e.g. estrangement from family, having only a few or no close friends and no work or purposeful activity. This can result in a low sense of self-worth and the maintenance of isolation. Social inclusion is ideally a collaboration between the psychologist, the inpatient and the Care Co-ordinator, e.g. finding voluntary work, contacting old friends, to best provide continuity of care.
- Post-discharge, two more therapy sessions are offered in the first month in the community. These sessions aim to offer some consistency and support when out of hospital.
- At the end of treatment, recommendation for further therapy can be made to the Care Co-ordinator.
- An audit is currently planned looking at user satisfaction which is sent to roughly 300 patients who have been seen for various amounts of time but on average for 4 weeks – keeping in mind that perhaps ¾ of those being referred to the CP on the ward, most or all other forms of treatment has been tried before.
- CPs also hope to have a impact on staff on the wards, e.g. by delivering regular training sessions and developing psychologically-oriented care plans with other disciplines.
- Groups for patients are run across all wards, e.g. the Leaving Hospital, Thinking Well and Hearing Voices groups.
Psychosis and Complex Mental Health Faculty of the British Psychological Society (BPS)
- Within the BPS there are different Divisions; Dr. Hanna is amember of the Division of Clinical Psychology and is Chair-Elect of one of its faculties, the Psychosis and Complex Mental Health Faculty.
- He is also Co-Chair of the Inpatient Psychological Practitioner Network.
- The Network arranges regular meetings and discussions about sharing best practice, setting standards and political initiatives e.g. the Mental Health Act. Network representatives communicate with the Government and campaign for greater access to psychological services for inpatients.
- Dr. Hanna feels that CPs have much to offer on acute wards, both in terms of service development and direct clinical care, and wonders why inpatients so rarely receive truly multidisciplinary care.
Questions
Insight of patients in their mental illness
- It is often requested by ward members to develop insight. Dr. Hanna thinks insight should be defined to link lived experience to what is distressing now, e.g. sexual abuse as a child and hearing voices. Here the aim is to make better sense of what has happened in life, thus raising consciousness which can sometimes be seen as a “breakthrough” (following “breakdown”) and can have a positive impact towards accepting help. This does not, in his view, mean forcing acceptance of a diagnosis. It is possible to understand links through formulation but fundamentally disagree with a specific diagnosis.
- Dr. Hanna’s style is to be accepting of individuals’ own perceptions of distress and admitting that he can be wrong when making interpretations to allow people not to take things too personally or feeling blamed. In CBT for psychosis the therapist should suspend his disbelief, and try to understand the experience of the person and then the origin of beliefs and safety behaviours can be explored subtly. If this doesn’t work, social costs can be discussed to encourage individuals to mobilise their resources in order to confront their situation. In this work, life history should be considered as the presentations are often complex.
Relationship between insight and compliance with medication
- Taking medication sporadically for a few months at a time reduces its effectiveness so the aim is to change how medication is seen, e.g. to accept that one has been through, for example, a trauma and is at risk of psychosis can make medication more acceptable, even when holding the belief that the diagnosis is wrong. Insight is understood as leading to behaviour change, which can apply to medication congruence as well as other desirable outcomes.
Recent changes – CPs involved in sectioning patients
- CPs can be involved in sectioning patients, where it is in the best interest of the patient to protect against, for example, emergent suicidal plans; this does not mean, necessarily, to bring their own patients to hospital. The Mental Health Act 2007 extends the role of the Responsible Medical Officer to CPs and other mental health professionals with the right level of experience. While noting that the Act places all professions on a more equal footing, with respect to CPs providing psychological therapy, there are, potentially, competing duties with consent based psychological care and containment for their safety to consider. This new role is more likely to be carried out in forensic settings, at least to start with.
Cost cuts leading to cuts in training places?
- Dr. Hanna does not expect much change in available places, just a growth of CP involvement in areas of risk and complexity, including acute wards and crisis services as opposed to a broadening of roles in primary care which will likely be served by a different skill mix than at present. There will be pressure on courses to teach more leadership and management skills: qualified CPs start as band 7 in the NHS which is the same as acute ward managers. Dr. Hanna took a leadership course himself after becoming a consultant. While he was initially hesitant to move beyond a more purely clinical role, he has found project management, strategy and policy, in particular, to be exciting and rewarding aspects to his work.
Dr. Hanna’s career trajectory?
- Trained in USA, mainly to serve people with severe and enduring mental health difficulties.
- He has mainly worked with CMHTs, but has also worked in an AOT.
Running groups on the wards?
- Leaving Hospital Group is run as an open discussion, as opposed to preplanning which exact topics will be discussed. Talk focuses around moving on from hospital and thoughts about leaving hospital with a now-towards-the-future orientation. Central concerns are developed after a few themes emerge, and the group works together to explore and find practical and psychological solutions to these concerns. It is often necessary to guide people back to the focus of the group; roughly every 3rd group is “difficult” due to unanticipated disruption—but the group is generally felt to be worthwhile.
Psychological testing on the wards?
- A variety of tests are applied for screening for different problems; WRAT/premorbid IQ tests, memory test when suspicion of Korsakoff's Syndrome, tests for impulse control and, primarily, the WAIS for general intellectual functioning.
- Trainees often help with testing.
Future of CPs
- Tim Cate, outgoing chair of Division of Clinical Psychology of the BPS believes that 50% of CPs won’t work directly for Trusts but will be contracted, working for private organisations.
- Dr. Hanna believes this may come to be true, but also that graduating CPs cannot rely on posts in “traditional” settings (eg psychology departments). There is likely to be a greater call for doctoral level expertise in areas of high risk and complexity—potential applicants would be advised to consider gaining experience in these areas. There could be a growth of CPs working with psychosis & at risk people, in crisis teams, CHMTs and assertive outreach teams – this means CPs will work where they are most needed, which will be challenging and stressful but also rewarding.
- There will be new Band 6 posts for Cognitive Behavioural Therapists (CBT therapists) which will be likely be regulated by the British Association for Behavioural and Cognitive Psychotherapies. These posts may provide an attractive alternative to other avenues should applicants find that they are not readily gaining interviews for clinical psychology training courses.
The group thanked Dr. Hanna for his time and sharing his ideas.