Intro to Clinical Health Psych UG Lecture 29.10.2024

INTRODUCTI ON TO CLINICAL HEALTH PSYCHOLOGY CLAIRE BOURNE [email protected] CONTE NT NOTIC E LEARNING OBJECTIVES/TODAY S SESSION Understand what Clinical Health Psychology is and what a Clinical Health Psychologist does Discover how relevant theoretical models...

INTRODUCTI ON TO CLINICAL HEALTH PSYCHOLOGY CLAIRE BOURNE [email protected] CONTE NT NOTIC E LEARNING OBJECTIVES/TODAY S SESSION Understand what Clinical Health Psychology is and what a Clinical Health Psychologist does Discover how relevant theoretical models help us understand the complex biological, psychological and social interactions related to physical health Identify the types of physical health conditions a Clinical Health Psychologist might work with, and the factors/mediators underpinning those Consider some psychosocial interventions used to address concerns related to physical health conditions Other important considerations as a Clinical Health Psychologist WHAT IS CLINICAL HEALTH PSYCHOLOGY? It is rooted in a strong scientific evidence base and encompasses a breadth of inputs to support optimal healthcare provision and improve clinical outcomes. It aims to provide ‘Psychologically Informed Care Pathways’, including Psychologically Informed Environments and Trauma Informed Care. It may offer certain inputs to achieve this. These will include providing specialist needs assessment, care planning and delivery of interventions usually within a multidisciplinary care context, to affect positive change for patients who may be facing distressing (BPS Explore, 2023) WHAT DOES THIS LOOK LIKE? A speciality, field and approach which addresses the psychological, social, cultural and biological factors as applied to physical health and wellbeing Applying knowledge in medicalised contexts Familiarisation with psychosocial dimensions of health Familiarisation with health-related behaviour Utilising knowledge of cognitive, social and clinical processes’ impacts on health behaviours to understand/address illness, injury and disability CONTEXT FOR DEVELOPMENT OF CLINICAL HEALTH PSYCHOLOGY Growing evidence over the last 4 decades that behaviour/thoughts/appraisals contribute to health status and quality of life Dissatisfaction with limits of biomedical approach (levers being consumerism, anti- professionalism, advocacy, dismissing expert- novice distinction) Shift to individual responsibility and prevention (but scope for shaming and stigma in neoliberal contexts) BIOPSYCHOSO CIAL MODEL BIOPSYCHOSOCIAL MODEL Physical problems such as unstable blood sugar, shortness of breath, incontinence, visible scars, etc. can adversely impact on psychological wellbeing and social integration, e.g., comorbid depression or anxiety Therefore, patients with long-term conditions may have unmet needs for psychotherapy, psychoeducation and social support M A Y C R E A T E A V I C I O U S C Y C L E O F M O R B I D I T Y … BIOPSYCHOSOCIAL MODEL Psychosocial problems such as depression, anxiety, embarrassment, shame, uncertainty etc., can adversely impact on physical health status: directly, e.g., psychoneuroimmunological pathways, indirectly, e.g., by poor adherence to treatment, unwillingness to report worsening of symptoms and get help Therefore, providing psychotherapy, psychoeducation and social support for patients with long-term conditions DELIVERING CLINICAL HEALTH PSYCHOLOGY Usually offered in acute settings and primary care, increasingly public health Services may specialise according to age (e.g., paediatrics) or condition (e.g., cardiology) Rubric that psychological principles, theory and practice are utilised to help those with physical health problems and/or disability  Significant difficulties in coping with ill health or its impact, regarding: Illness/symptoms Treatment FOCUS OF DELIVER Recovery/complications Y Quality of Life Family/carers/staff Healthcare utilisation LET ’ S WALK IN TONY ’ S SHOES Tony is 38 years old, married to Julie (34), with 2 sons, aged 8 and 6. He has been fit to date, a keen amateur rugby player and enjoys coaching his sons. He works for the council in conservation, and despite cutbacks, has just been promoted. Julie has a new part-time job, as the boys are both at school, but also runs a Pilates class two evenings a week. Tony’s parents live locally. Tony is concerned for his parents since his father had a stroke two years ago and his mother’s arthritis is limiting her mobility. Tony has experienced a dragging of his left foot for two months, an episode of double vision and has noticed recurrent pins and needles in his left hand for almost a year....His GP has referred him to a neurologist and symptoms and scans suggest MS. WHAT IS MS? https://youtu.be/nw2K 5vDA1Zk OVER TO YOU… What do you consider to be the major challenges of having a chronic, possibly life- limiting physical illness?  QR CODE FOR PADL ET COMMON RESPONSES Anger Anxiety Frustration Helplessness Hopelessness Irritability Physical Resentment/ impacts (e.g., Sadness envy tension) Stress WHAT MIGHT AFFECT IMPACT? Diagnosis (how, when, meaning) Point in life cycle Adjustments Treatments (or their absence)/concordance Side-effects/ iatrogenesis Co-morbidities Palliation End of life  Clients with Health Anxiety (continuum) WHO MIGHT A Clients with unexplained physical symptoms CLINICAL Clients with diagnosed health problems (cardiovascular, diabetes, cancer, pain, renal, HEALTH dermatological, neurological, disfigurement, sexual) PSYCHOL OGIST Staff (delivering care and its impact) SEE? The system (primary/secondary/tertiary/preventative) WORKING WITH ADULT CLIENTS WHO ARE ILL Making sense of the condition Accommodating change Time of life Impact on self-identity Impact on couple/systems Losses and gains Impact of gender/ethnicity/religion/community beliefs or other protected characteristics Impact of caregiving Stigma Maintaining dignity and QoL HOW MIGHT YOU APPROACH… DOMAINS TO EXPLORE? Telling the tale/sharing the story of illness Reducing the pace Normalising the impact of illness Considering its emotional impact Meanings of illness and/or disability Impact on relationships Impact on lifestyle  PROCESS WHILST ASSESSING 01 02 03 04 05 Respecting the Addressing Addressing Identifying Preparing for individual’s misunderstand communicatio resources the future agency/family ings n issues authority with/outwith family MODELS OF WORKING All the main therapeutic models can be applied to working in clinical health settings, growth of 3rd wave approaches e.g., CFT, ACT (Graham et al., 2016; Zarotti et al., 2022 for MS). Irrespective of theoretical orientation, psycho-education is important. Specific Health Psychology models should be able to inform assessment, formulation and interventions (Ogden, 2004; Conner & Norman, 2015; French et al., 2010)  WHAT ARE ILLNESS PERCEPTIONS? “A patient’s own implicit common-sense beliefs about their illness” (Leventhal et al., 1980, 2007a, 2007b; Leventhal and Nerenz 1985) They provide patients with a framework or schema for coping with and understanding their illness These perceptions/beliefs are influenced by a range of factors: – information presented by healthcare professionals – prior experience with the illness – information gained from the social context – cultural beliefs These beliefs are that they have a significant impact on the behaviours an individual uses to cope and manage their illness and therefore on outcomes including both clinical and quality of life (Dempster & McSharry, 2015). MODEL OF ILLNESS BEHAVIOUR Illness perceptions tend to be discussed in terms of the Self-Regulatory Model Self-Regulation is a dynamic process in which the individual attempts to preserve the sense of self and to solve the problem of what is happening to their health THE SELF-REGULATORY MODEL (LEVENTHAL, 1980, 2007A) Representation of health threat (Illness perceptions) Identity Consequences Timeline Control/cure Causes Illness coherence Emotional Stage 2: Coping Stage 3: Stage 1: Interpretation representations Approach Appraisal Symptom perception coping Was my coping Social messages – Avoidance strategy deviation from norm effective? coping Emotional response to health threat Fear Anxiety Depression ILLNESS PERCEPTIONS/REPRESENTATI ONS The label given to the illness (medical diagnosis) and the Identity: symptoms experienced. Patients’ perceptions of the possible effects of the illness Consequences: on their life. These may be physical, emotional or a combination of factors. Beliefs about how long the illness will last, whether it is Timeline: acute or long-term. Beliefs about whether the illness can be treated and cured, and the extent to which the outcome of their Control/cure: illness is controllable either by themselves or powerful others (e.g., doctor). Causes: Perceived causes (biological or psychosocial). Illness coherence: Comprehension or understanding of the illness. Emotional Perception of negative emotions generated by the representations: illness. THE IMPORTANCE OF BELIEFS (Lewin angina 1997) at lower level of activity “angina is a mini heart deconditioning less efficient attack” use of oxygen in myocardium reduce activity to prevent angina & further damage to heart THE IMPORTANCE OF BELIEFS (Lewin 1997) decreasing frequency of angina, higher ischaemic threshold “Angina doesn‟t do development of any lasting collateral blood harm” supply to ischaemic area Keep active - repeated ischaemic challenge WHAT CAN WE DO WITH ILLNESS PERCEPTIONS WITH REGARDS TO WORKING WITH PATIENTS? How do we elicit illness How can we address illness perceptions? perceptions? Measure using IPQ-R (Moss- Self-management Morris et al., 2002) programmes Ask questions during Rehabilitation programmes consultations Behaviour change techniques (BCTs) CBT Providing psychoeducation/informatio n COPING WITH ILLNESS: THREE APPROACHES 1. Coping 2. with the Adjustment crisis of to physical illness illness 3. Benefit finding: Post- traumatic Growth COPING WITH ILLNESS: THREE APPROACHES 1. Coping with the crisis of illness 2. Adjustment to physical illness 3. Benefit finding: Post-traumatic growth 1. Relates to grief and CRISIS mourning of change THEORY after crisis The coping process: Cogniti ve Adaptiv Coping Apprais e tasks Skills al (Moos & Schaefer, 1984) 2. COGNITI Adjusting to VE threatening events ADAPTIO N THEORY The coping process: Process of Search for Search for self- meaning mastery enhancem ent (Taylor, 1983; Taylor et al. 1984)  Previous theories focus on return to 3. POST ‘normality’ but that is often something TRAUMAT that is lost and has a negative focus IC PTG based in positive psychology GROWTH Although some negative consequences for lifestyle and quality of life, people can consider life to have improved Silver Lining Questionnaire (Sodergren et al, 2002) Positivity can be improved by rehabilitation ADHERENCE TO TREATMENT What makes people more likely to adhere? Perception of symptoms Belief of its seriousness Belief in treatment Family and social input (Shahaj et al. 2019) OVER TO YOU… Go back to the Padlet, this time think about any illness representations Tony might have and how these might affect his coping style illness  QR CODE FOR PADL ET HEALTH AND HEALTH BEHAVIOUR “Health is a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity” (WHO, 1946) Recent definitions include cultural, psychosocial and economic elements ‘Health and illness are two countries. If we’re lucky we live in the world of health, but we all hold passports to the world of illness’ (Susan Sontag, 1991) DETERMINANTS OF HEALTH ( D A H L G R E N & W H I T E H E A D 1 9 9 1 )  Although some of the variations in older people’s health are genetic, most is due to people’s physical and social environments – including their homes, neighbourhoods, and communities, as well as their personal characteristics – such as their sex, ethnicity, or socioeconomic status. The environments that people live in as children – or even as developing fetuses – combined with their personal characteristics, have long-term effects on how they age. DETERMIN Physical and social environments can affect health directly or through barriers or incentives that affect ANTS OF opportunities, decisions and health behaviour. Maintaining healthy behaviours throughout life, HEALTH particularly eating a balanced diet, engaging in regular physical activity and refraining from tobacco use, all (WHO, contribute to reducing the risk of non-communicable diseases, improving physical and mental capacity and delaying care dependency. 2024) Supportive physical and social environments also enable people to do what is important to them, despite losses in capacity. The availability of safe and accessible public buildings and transport, and places that are easy to walk around, are examples of supportive environments. In developing a public-health response to ageing, it is important not just to consider individual and environmental approaches that ameliorate the losses associated with older age, but also those that may reinforce recovery, adaptation and psychosocial growth. REGARDING HEALTH, WHAT MIGHT YOU BE HELPING TO CHANGE? DOMINANT HEALTH ISSUES AND THEIR BEHAVIOURAL UNDERPINNINGS Major conditions strategy: case for change and our strategic framework (2023) INTERVENTIONS (BPS GUIDE TO PSYCHOSOCIAL INTERVENTIONS IN EARLY STAGE DEMENTIA, 2022?) Adjustment e.g., CFT Managing stress, distress, anxiety and depression e.g., CBT CFT Family/systemic therapy Stress/anxiety management Improving and maintaining cognitive function e.g., Cognitive Stimulation Therapy (CST) and maintenance CST Maintaining quality of life e.g., Cognitive Stimulation Therapy (CST) and maintenance CST Life story work CARDIOVASCU LAR DISEASE Up to 80% of premature CVD deaths are preventable. High blood pressure, high cholesterol, diet, obesity, physical inactivity, smoking and air pollution explain the vast majority of CVD, and in some cases exposure to these risk factors is increasing. Action on the wider socio-economic determinants of health also plays a role in reducing CVD. For example, living in cold homes, low income, debt or poor-quality housing, increases the risk of heart attack or stroke. THE POTENTIAL ROLE OF PSYCHOLOGY IN CHD Beliefs Susceptibility ”I won’t have a heart attack” Seriousness “Lots of people recover from heart attacks” Rehabilitation Coping Behaviour change Costs “Taking exercise would be an with Belief change effort” illness Benefits “smoking helps me deal with stress” Outcome Longevity Illness onset: Heart Recovery CHD attack Quality of life Behaviours Diet Illness Illness Exercise representati as Smoking ons stressor Screening Type A Behaviour INTERVENTIONS Cardiac Rehabilitation – BACR specify need for Psychologist to be part of Cardiac Rehab Team Self-management support interventions? E.g., The Heart Manual (Deighan et al., 2017) MBSR: Jalali et al., (2019) Self-efficacy and quality of life of cardiovascular patients could be improved by providing an MBSR program. CBT: Reavell et al., (2018). Cognitive behavioral therapy seems to be an effective treatment for reducing depression and anxiety in patients with CVD and should be considered in standard clinical care. CANCER Obesity and alcohol increase the risk of several types of cancer; these are the most important nutritional factors contributing to the total burden of cancer worldwide (Key et al., 2020) Stopping smoking, reducing alcohol consumption, engaging in physical activity, improving diet and reducing excess weight can all reduce the risk of cancer. The incidence of cancer is also associated with deprivation, with greater prevalence in more deprived areas.  HOPE Programme (see next slide) Other self-management support programmes INTERVEN Park et al., (2019): Results suggest psychosocial TIONS interventions (e.g., meaning-focussed group therapy, MBSR) are associated with small-to- medium effects in enhancing meaning/purpose among cancer patients, comparable benefits to interventions designed to reduce depression, pain, and fatigue in patients with cancer. Saur et al., (2024): Recent meta-analyses and reviews suggests that ACT interventions are an effective and evidence-based treatment for increasing HRQoL and reducing psychological distress in patients with cancer.  T H E H O P E P R O G R A M M E H T T P S : / / W W W. H 4 C. O R G. U K / H O P E - P R O G R A M M E MEDIATORS: SMOKING Smoking is the leading cause of preventable ill health and death in England, and a significant contributor to inequalities in life expectancy. It is also the single biggest avoidable cause of death and disability in developed countries. It puts people at high risk of developing cancer, cardiovascular and respiratory diseases, and was responsible for nearly 75,000 deaths and more than 500,000 hospital admissions in England in 2019 (Health Foundation, 2020). Smoking increases as SES diminishes - although reduction in overall prevalence, masks relative static use in socially disadvantaged groups. MEDIATORS: EXERCISE/PHYSICAL ACTIVITY Physical activity can help to prevent and manage overweight and obesity and protect against a range of noncommunicable diseases including cardiovascular disease and diabetes. Has positive effects on mental health and can support social inclusion. In 2019, an estimated 10,000 deaths were attributable to low physical activity. Although the relative impact on morbidity and mortality is lower for physical activity than poor diet, increased physical activity provides additional benefits, including prevention of falls and fractures (Health Foundation, 2020). Obstacles – time, lack of support/norms, self- image, energy, skill, fear of injury, resources MEDIATORS : ALCOHOL Alcohol consumption can negatively impact nearly every organ in the body, causing liver disease, heart disease, cancer, and mental health problems. It was the main reason for 320,000 hospital admissions in 2019/20, with 6,984 alcohol-specific deaths in England in 2020, a 20% increase on the previous year. Harmful alcohol use also has a significant social impact, increasing the risk of accidents, violence, child neglect and antisocial behaviour (Health Foundation, 2020). OTHER PRACTICAL FACTORS/CONSIDERA TIONS AS A CLINICAL HEALTH PSYCHOLOGIST ASSESSMENT AND OBSTACLES Legitimacy (end of road, scrutinised, medical context) Engagement/wariness particularly if referral poorly communicated Physical difficulties (where and when seen) – what of the acute setting? (Privacy/sensitivity/interruption) Therapist potentially feeling overwhelmed since not their domain, yet need familiarity with medical terminology Expertise of an individual/family (patronised? pathologised? cultural nuance) HEALTHCA RE SETTINGS Ensure able to preserve client: – Dignity – Privacy – Confidentiality To foster honesty, trust and compassion ESTABLISHIN G A RATIONALE Acknowledge the medical route of referral and consider/shape role of psychologist Establish nature, history, impact of health problems thoroughly Acknowledge reality of patients’ experience since may have been dismissed Normalise the referral Explore links between health and psychological factors which are acceptable to the patient Remember language FURTHER IMPORTANT CONSIDERATIONS Be flexible in timing and negotiate movement during session if discomfort/fatigue an issue. Invite clients to let you know of discomfort. Consider how/what you modify if at bedside. Seek to structure and prioritise problems – physical and broader psychosocial issues. QUESTIONS?  REFERENCES British Psychological Society. (2022). A guide to psychosocial interventions in early-stage dementia. (2 nd Edition). https://explore.bps.org.uk/binary/bpsworks/da909d7b06a43358/16f7daf5a6fa5cea388840a1448f303d9571cf0a6 be8508163110977f129f8a8/rep101c_2022.pdf Conner, M, & Norman, P. (2015). Predicting and Changing Health Behaviour: Research and Practice with Social Cognition Models. McGraw-Hill Education. Deighan, C., Michalova, L., Pagliari, C., Elliott, J., Taylor, L., & Ranaldi, H. (2017). The Digital Heart Manual: A pilot study of an innovative cardiac rehabilitation programme developed for and with users. Patient education and counseling, 100(8), 1598–1607. https://doi.org/10.1016/j.pec.2017.03.014 French, D., Vedhara, K., Kaptein, A. A., & Weinman, J. (Eds.). (2010). Health psychology. John Wiley & Sons. Graham, C. D., Gouick, J., Krahé, C., & Gillanders, D. (2016). A systematic review of the use of Acceptance and Commitment Therapy (ACT) in chronic disease and long-term conditions. Clinical psychology review, 46, 46–58. https://doi.org/10.1016/j.cpr.2016.04.009 Health Foundation. (2020.) https://doi.org/10.37829/HF-2022-P10. Jalali, D., Abdolazimi, M., Alaei, Z., & Solati, K. (2019). Effectiveness of mindfulness-based stress reduction program on quality of life in cardiovascular disease patients. International journal of cardiology. Heart & vasculature, 23, 100356. https://doi.org/10.1016/j.ijcha.2019.100356 Key, T. J., Bradbury, K. E., Perez-Cornago, A., Sinha, R., Tsilidis, K. K., & Tsugane, S. (2020). Diet, nutrition, and cancer risk: what do we know and what is the way forward?. BMJ (Clinical research ed.), 368, m511. https://doi.org/10.1136/bmj.m511 Ogden, J. (2019). Health Psychology. 6th Ed. McGraw Hill. Park, C. L., Pustejovsky, J. E., Trevino, K., Sherman, A. C., Esposito, C., Berendsen, M., & Salsman, J. M. (2019). Effects of psychosocial interventions on meaning and purpose in adults with cancer: A systematic review and meta-analysis. Cancer, 125(14), 2383–2393. https://doi.org/10.1002/cncr.32078 Reavell, J., Hopkinson, M., Clarkesmith, D., & Lane, D. A. (2018). Effectiveness of Cognitive Behavioral Therapy for Depression and Anxiety in Patients With Cardiovascular Disease: A Systematic Review and Meta- Analysis. Psychosomatic medicine, 80(8), 742–753. https://doi.org/10.1097/PSY.0000000000000626 Sauer, C.A., Haussmann, A., & Weissflog, G. (2024). The effects of acceptance and commitment therapy (ACT) on psychological and physical outcomes among cancer patients and survivors: An umbrella review. Journal of Contextual Behavioral Science, 33. https://doi.org/10.1016/j.jcbs.2024.100810 World Health Organisation. (2024). https://www.who.int/news-room/fact-sheets/detail/ageing-and-health Zarotti, N., Eccles, F., Broyd, A., Longinotti, C., Mobley, A., & Simpson, J. (2023). Third wave cognitive behavioural therapies for people with multiple sclerosis: a scoping review. Disability and rehabilitation, 45(10), 1720–1735. https://doi.org/10.1080/09638288.2022.2069292