All Clin MH Powerpoints (for exam) PDF

Related image 3 Wave therapies rd Rebecca Gould, Professor of Psychological Therapies & Honorary Clinical Psychologist, Outline What are 3rd wave therapies? Why do we need a 3rd wave of therapy? What is Acceptance & Commitment Therapy (ACT)? What are Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT)? What is Compassion-Focused Therapy (CFT)? What is Dialectical Behaviour Therapy (DBT)? What are 3 wave therapies? rd 1st Wave Behaviour Therapy 2nd Wave Cognitive Therapy Cognitive Behavioural Therapy 3rd wave Acceptance and Commitment Therapy (ACT) Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR) Compassion-Focused Therapy (CFT) Dialectical Behaviour Therapy (DBT) (Hayes, 2004, 2016) Why do we need a third wave of therapy? People experience negative thoughts that are realistic Control-orientated strategies can be detrimental to a person’s psychological wellbeing People experience problems that can’t be solved No additional benefit of adding cognitive restructuring to behavioural activation What is Acceptance and Commitment Therapy (ACT)? What is ACT? “ACT is a therapy approach that uses acceptance & mindfulness processes and commitment and behaviour change processes to produce greater psychological flexibility.” Hayes et al. (2004) “Psychological flexibility is the ability to contact the present moment more fully as a conscious human being and to either change behaviour or persist, when doing so serves valued ends.” Wilson & Murrell (2005) Key principles Not aimed at reducing distress or symptoms Aims to help people to: i) be more open to and accepting of their experiences; ii) become more aware of their experiences in the here- and-now; iii) commit to doing things guided by what really matters to them. Key principles Lack of contact with the present moment Contact with the present moment Experiential avoidance Lack of clarity or loss of contact with Acceptance/willingness PSYCHOLOGICAL values INFLEXIBILITY Values PSYCHOLOGICAL FLEXIBILITY Inaction, impulsivity Cognitive fusion or avoidant Defusion persistence Self-as-content Committed action Self-as-context Background: 68 year old woman with GAD. An example Was previously helping out at her local church and looking after her grandchildren on a regular basis. Lack of contact with the present moment Worrying about the future, ruminating Experiential avoidance about things that have happened in the Drinking wine and takingpast, finds it difficult to keep her mind on Lack of clarity or loss of Valium to feel calmer, things contact with values keeping busy at home to Loss of contact with distract herself, seeking values in relation to being reassurance, avoiding PSYCHOLOGICAL caring and spiritual responsibility INFLEXIBILITY Cognitive fusion Inaction, impulsivity or avoidant “I’m going to make a persistence mistake”, “Something bad is going to happen”, No longer helping out Self-as-content “What if…?”, “I can’t do at the church or looking anything when I’m “I’ve always been a worrier”, “I’m after her grandchildren feeling really anxious” useless” An exercise… Imagine a thought on a computer screen exercise Evidence base Review of meta-analyses (Gloster et al., 2020) Effect sizes in favour of ACT compared to controls for chronic pain, anxiety, depression, substance use and transdiagnostic groups Growing evidence base Chronic conditions (e.g. Graham et al., 2016) Clinical recommendations NICE recommends ACT for: Chronic pain https://www.nice.org.uk/guidance/ng193 Resources Books and booklets Harris, R. (2019). ACT made simple (2nd edition). WHO’s “Doing what matters in times of stress” booklet: https://apps.who.int/iris/bitstream/handle/10665/33 1901/9789240003910-eng.pdf Websites ACT in Context podcasts https://contextualscience.org/podcast Free worksheets, handouts, videos, audio, etc (Russ Harris) https://www.actmindfully.com.au/free-stuff/ What is Mindfulness-Based Stress Reduction (MBSR) and Mindfulness- Based Cognitive Therapy (MBCT)? What is mindfulness? Feelings Moment by Non judgement moment Mindful awareness Bodily Thoughts sensations Openness & curiosity Source: http://mindfulnet.org/ Mindfulness is not… http://jurnalparanormal.ro/sites/default/files/2_22.jpg https://encrypted-tbn2.gstatic.com/images?q=tbn:ANd9GcSkitq12kk4lu9Wgp-1uF3UzypmMelgCcDJuSZrEXl-MRu1lSHZ Image result for focused attention What are MBSR and MBCT? Mindfulness-Based Stress Reduction (MBSR) Developed for people with chronic pain/medical conditions Mindfulness-Based Cognitive Therapy (MBCT) MBSR plus elements of CT for depression Developed for people with recurrent depression Mindfulness for life (MBCT-L) MBCT plus positive psychology principles Developed for general population (e.g. workplace) Key principles Shifting from the “doing mode” to the “being mode” Stepping out of “automatic pilot” Choosing how to respond to difficulties... MBCT & MBSR: Similarities & differences An exercise… 3 step breathing space Evidence base McCartney et al. (2021) Overall risk of relapse was smaller for MBCT compared to TAU Overall time to relapse of depression was longer for MBCT compared to TAU and placebo Goldberg et al. (2019) Overall effect size in favour of MBCT compared to controls for current depression Clinical recommendations NICE recommends group MBCT for: Preventing relapse in depression Less severe depression https://www.nice.org.uk/guidance/ng222 http://franticworld.com/wp-content/uploads/2011/06/Cropped-Book-Cover-Hi-Res.jpg Resources Books Williams, M., & Penman, D. (2001). Mindfulness: A practical guide to finding peace in a frantic world. Videos “Healing from within”: https://vimeo.com/39767361 Websites Free online MBSR course: palousemindfulness.com/index.html Free meditations http://franticworld.com/free-meditations-from- mindfulness/ Free resources https://www.oxfordmindfulness.org/learn- mindfulness/resources/ What is Compassion-Focused Therapy (CFT)? What is CFT? Originally developed to help people experiencing complex mental health problems linked to high levels of shame and self-criticism (Gilbert, 2009) Integrates CBT principles with those from neuroscience, attachment theory, evolutionary psychology, social psychology and Buddhist psychology (Gilbert, 2014) Aims to help people develop and work with experiences of inner warmth, safeness and soothing, via compassion and self-compassion (Gilbert, 2009) Key principles “DEMANDS” “Should” “Must” …get back to normal …keep on top of everything …feel energetic and cheerful The Compassionate Mind “Inner critic” (Paul Gilbert, 2010) Key principles Threat system Drive Soothing system system Motivation Survive Achieve, win Look after, soothe Focus of Rapid threat Aims, goals Empathy to attention detection distress Thoughts About danger Striving, Caring, achieving soothing Emotions Fear, anxiety, anger Positive, Safeness motivational Physiologic Highly aroused Aroused Calm al sensations Key principles “DEMANDS” “Should” “Must” …get back to normal …keep on top of everything …feel energetic and cheerful The Compassionate Mind “Inner critic” (Paul Gilbert, 2010) Background: 47 year old man with prostate cancer. Historically worked part- An example time and raised 2 young children on his own. Beating self up about the diagnosis “Why didn’t I go to the doctor earlier? This is my fault.” Had to stop chemotherapy early as side effects were affecting him too much. “Why couldn’t I handle it?… I’m weak.” Not resting and taking advice of nurses/doctors “I’ve let my family down and need to keep going as normal.” An exercise… Compassionate colour exercise Evidence base Millard et al. (2023): Overall effect size in favour of improving self- compassion and self-reassurance compared to controls But more high-quality research is needed into long- term effects before any clinical recommendations can be made Resources Books Gilbert, P. (2010). The Compassionate Mind. Videos The science of compassion – Paul Gilbert https://www.youtube.com/watch?v=e2skAMI8c-4 Websites The Compassionate Mind Foundation https://www.compassionatemind.co.uk Free worksheets, videos, audio, etc https://www.compassionatemind.co.uk/resources What is Dialectical Behaviour Therapy (DBT)? What is DBT? Originally developed to treat chronically suicidal individuals and women with borderline personality disorder (BPD) and a history of suicidal or self-injurious behaviour (Linehan, 1993) People with BPD lack important interpersonal, self- regulation, and distress tolerance skills Aims to help people with BPD engage in functional, meaningful behaviour in the presence of intense emotions Key principles 4 behavioural targets: Reduce life-threatening suicidal acts and self-harm Decrease behaviours that interfere with therapy Reduce behaviours that interfere with quality of life Increase behavioural skills Key principles Weekly group sessions for 12 months PLUS Weekly individual sessions for 12 months PLUS Telephone crisis coaching for 12 months An example…  Balancing emotional urges exercise Emotion Emotion-driven urge Opposite behaviour to urge Anger Attack, criticise, hurt, Be polite, be more gentle or shout nice, validate, use soft voice Anxiety/ Avoid, hunch shoulders Approach, do what is being fear avoided, remain, stand tall Sadness Shut down, avoid, Seek support, socialise, be withdraw, be passive, active, get involved, stand slump straight Shame, Punish yourself, avoid, Approach others, share your guilt shut down, hang head thoughts, make amends (if appropriate), raise head An example… Step Questions to ask yourself… 1. Situation What is the situation? 2. Emotion & What emotion am I feeling? effectivenes What emotional urge am I noticing? s of What’s my posture, facial expression, tone of emotional voice? urge Would expressing my natural emotional urge be useful and effective in this situation? 3. Act the If no, how can I act in the opposite way to my opposite way emotional urge? 4. Test, Try it out. What happened before, during and reflect and after? Is this a more useful or effective strategy? An example… Step An example… 1. Situation I have to give a presentation, which I’ve been preparing for 2 weeks. 2. Emotion & I feel very anxious (emotion) as I think I’ll mess it up effectiveness and look stupid in front of other people. of emotional I am thinking about calling in sick and cancelling the urge presentation (emotional urge). I've been working really hard for this and it's probably not justified or useful for me to do this (effectiveness of emotional urge). 3. Act the I should go with the feelings of anxiety and do the opposite way presentation even though I know it’ll feel uncomfortable. 4. Test, I felt really uncomfortable presenting my work but I Evidence base DeCou et al. (2019) Overall effect size in favour of DBT for reducing self- directed violence and frequency of psychiatric crisis services but not suicidal ideation compared to controls Stoffers-Winterling et al. (2022) Overall effect size in favour of DBT for reducing self- harm and improving psychosocial functioning compared to controls in people with BPD BUT only 3 studies included in meta-analysis of DBT Clinical recommendations NICE recommends DBT for: Women with BPD where suicidal or self-injurious behaviour is a priority https://www.nice.org.uk/guidance/cg78 Resources Books Linehan, M.M. (2015). DBT skills training manual. Videos DBT: Where we were & where we are - Marsha Linehan https://www.youtube.com/watch?v=hM_Pj_MvpcM Websites The Linehan Institute https://linehaninstitute.org DBT: Dialectical Behavior Therapy https://dialecticalbehaviortherapy.com Thank you for listening – any questions? Assessment, Diagnosis and Formulation Prof Jo Billings UCL Division of Psychiatry Clinical Mental Health Module MSc Clinical Mental Health Sciences / Mental Health Sciences Research Overview What do we need to assess and why? How do you do an assessment? What is the difference between diagnosis and formulation? Practice! Diagnosis/ Assessment Intervention Formulation What to include? What things might you want/need to ask when doing an assessment? What to include? What is the purpose of your assessment? What setting is assessment taking place in? How much time do you have? What do you need to know? What does the patient need to tell you? What to include? What is the problem(s) What keeps the problem Nature of the problem going (maintaining Recent example factors) How did the problem Biological develop Social When did it start Psychological How has it developed Environmental Systemic What caused the problem Historical factors Triggers The 5 ‘P’s 1. Problems 2. Predisposing factors 3. Precipitants 4. Perpetuating factors 5. Protective factors What to include? Risk Previous treatment Person’s goals Engagement with services/current treatment plan Motivation to change When is the problem not a problem Strengths, resources and resilience How to do an assessment? “Conversation with a purpose” Open vs closed questions Open Questions Closed Questions What has brought you What impact has this had here today? on your sleep? Tell me about when you When did you last work? first noticed your mood Have you taken anti- was low? depressants before? What was your Did you find your experience of previous previous therapy helpful? treatment like? Diagnosis vs Formulation Diagnosis Formulation DSM-V, ICD 11 Idiosyncratic Specific disorder labels Why does this particular i.e. Major Depressive person have this Disorder, OCD, PTSD particular problem at this Relevant research and particular time? literature Helps tailor intervention Evidence-based to specific individual interventions Formulation What is the problem? When did it start? How has it developed? What earlier life experiences may have predisposed the patient to developing this problem? What is keeping the problem going now? What strengths/resources does the patient have to overcome the problem? Formulation - Narrative Mr Brown is presenting with symptoms consistent with the diagnosis of PTSD following a physical assault last year. It seems that this has triggered further memories of having been bullied at school and confirmed beliefs that he is weak and vulnerable. Since the assault Mr Brown has been avoiding reminders of the assault, such as watching violent programmes on TV and trying not to talk to anyone about what has happened, which is preventing him from processing his memories of the attack. He has also been avoiding going out on his own or at night, which is preventing him from disconfirming his belief that he is likely to be attacked again. Mr Brown is very motivated to engage in therapy and has support from his partner and friends. He has been determined to continue to going to work and attending the gym. Exercise – Role Play - Sam MHP: Mental health professional working in a primary care mental health service. Patient: 36 year old on parental leave from role as a marketing manager, referred by health worker Exercise – Role Play - Chris MHP: Mental health professional working in a community mental health team Patient: 42 year old referred by GP with physical symptoms and low mood. Currently signed off of work. What did you find out? Sam Chris ▪ What did you find out? ▪ What did you find out? ▪ What is your diagnosis? ▪ What is your diagnosis? ▪ What is your formulation? ▪ What is your formulation? Questions Clinical Workshop: Introduction to family work Dr Naomi Glover Overview Why do we work with families? Genograms Review of genograms Task Overview of systemic therapy Group clinical task & feedback Why would we work with families? Genograms A genogram is a a map of the family system, including familial and emotional connections between people Developed with the individual or family and used to understand the different connections and links Emphasises a view of connection and relationships beyond the immediate family Genogram example - Harry Potter Verno Petuni James Lily n a Dudle Harry Arthur Molly y Bill Charli Percy Fred Georg Ron Ginny e e Task In pairs, share an aspect (familial relationship, emotional connection or important person) of your genogram with you partner. Why was this the part you picked? What did it feel like to write your own genogram? Systemic Approach Systemic therapy sees any social group as a ‘system’ Each and every person’s behaviour affects others and is affected by others These interactions and particularly common patterns of interactions can be helpful or unhelpful Rather than ask ‘who is ill?’ it asks ‘how does this system (through alliances, assumptions, and interactions) maintain this problem?’ Systemic therapy – a very brief history Structural Mental health difficulties viewed as an indication that the family organisation is dysfunctional. A strong focus on altering the family structure. Strategic Problems are viewed as having a function within the family and involve a sequence of repeated behaviours between people. Post Milan Increasing focus on social constructs and the language used to describe behaviours and experiences Concepts: Context Each person in the system has a different perspective and there is no definitively correct external view Problem behaviours are only problematic in light of the situation in which they occur There is typically a tension between individual and group needs, autonomy and intimacy Key principles of systemic therapy Everyone is involved in “the problem” it’s not something which is located in the individual Deconstruction of the problem – what is the problem from everyone’s perspective Hypothesising and tentative stance A “non-expert” position Problems arise from failing solutions to difficulties Transitions in the family system are important – e.g. death, separation, illness, birth, relocation Contextual factors – within the family and external to the family Task Kai is a 15 year old girl who has been refusing to go to school for the last 3 months, since she started year 11. Her grades have previously been excellent but there are concerns that this now that she is not attending lessons. The family have been referred to child and adolescent mental health services and have an appointment to meet with a psychologist for an assessment. The family are: Kai (client), Ruth (mum, 47), Jay (dad, 52), Amber (older sister, 18), Chris (granddad, 72) Task For your family member: What are the problem(s)? How does the problem affect relationships? How do relationships affect the problem? Who is most impacted by this problem? After the task: Feedback from each family member What does systemic therapy look like? Systemic therapy can be practiced in a number of ways Individual therapy informed by systemic thinking Couple or family work Reflecting team – in and out of the room Family work is also relevant to a number of settings: Child and adolescent services Physical health services Older adult services Psychosis services Eating disorders services Questions Associate Professor, Sarah Rowe, Division of Psychiatry, UCL Clinical Mental Health Introduction to Personality Disorders (PDs) (Part 1) Learning Learning objectives Objectives Pre-lecture recording: To define the features of a PD To provide an overview of the prevalence and causes of PD To critically discuss models of PDs To provide a summary on the assessment of PDs Personality Personality Think of it as a spectrum Healthy Some Many Personality personality problematic problematic Disorder functioning traits traits Elements of Personality Functioning Self: 1. Identity 2. Self-direction Interpersonal: 1. Empathy 2. Intimacy What is a personality disorder (PD)? Enduring pattern of dysfunctional inner experience and behaviour The 3Ps: Pervasive, Problematic, Persistent Defining features of PD Four defining features of PDs: Distorted thinking patterns Problematic emotional responses Over or under regulated impulse control Interpersonal difficulties Regulation – clarifying terms Regulation = the ability of being able to adjust as a response to change self-regulation = internal (individual/self) response to change Co-regulation = social relationships and the way one can adjust themselves when interacting with another Dysregulation = the inability to control the emotional response outside of the ‘typically’ accepted range. Epidemiology (1) How common are personality disorders? - WHO estimates 6.1% - Community: Global pooled prevalence 7.8% (95% CI 6.1-9.5) (Winsper et al, 2019). Meta- analysis of adult population in Western countries 12.6% for any PD (Volkert et al., 2018) - Lower rates in LMICS compared to high income countries (4.3% vs 9.4%) - Approx 2.5 million people in UK (Coid, 2006) Epidemiology (2) Gender differences e.g. Cluster A and Antisocial PD ↑men than women Ethnicity? Some evidence suggests lower rates of PD among African American people Prevalence rates may decline with increasing age Estimated life expectancy at birth of patients with personality disorder (Fok et al., 2012) Aetiology (1) Aetiology (1) Aetiology (2) Genetics – heritability of traits and PDS range from 30- 60% (Reich-Kjennerud, 2008; Leichsenring et al., 2011) Possible link between early trauma and later neurobiological dysfunction e.g. serotonin (5-HT) system, hypothalamus- pituitary-adrenal (HPA) axis Dysfunctional frontolimibic network Aetiology (3) Early experiences e.g. Attachment, childhood adversity - Those who experienced childhood abuse or neglect more than 4x more likely to be diagnosed with PD - Attachment Theory (Bowlby, 1973) e.g. BPD associated with preoccupied attachment Aetiology (4) Winsper (2018), Current Opinion in Psychology Models of Personality Disorders Categorical Model Current and “official” method In this model you either have a disorder or you do not This model assumes each personality disorder is a separate and distinct category (i.e. separate from other personality disorders and distinct from “normal” personalities Categorical Models of PD (1) ICD-11 DSM-5 Themes Cluster Paranoid Rightousness/innocent, others A Has discarded malicious, be Odd classification into wary/counterattack clinical groups Schizoid Loner, other intrusive, stay away Schizotypal Odd/unusual, others dangerous, Replaced with mistrust/stay away dimensional Antisocial Autonomous/strong, others B classes: mild, vulnerable, attack/manipulate Dramatic moderate, severe Borderline Unstable self/emotions, others idealised/cruel, avoid Symptoms no abandonment/emotion longer have to Unstable emotions, poor begin in early impulse and aggression control adulthood provide Histrionic “Glamourous”, others they’ve been “seducible”, use there for 2 years charm/dramatics Narcisstic Sepcial/unique, others inferior, Behaviours use others and break rules involving Avoidant Socially inept, others critical, C significant self- avoid evaluation Anxious harm wold Dependent Helpless/incompetent, others automatically lead idealised, cultivate dependency to a diagnosis of Obsessive- Responsible/competent, others severe PD Compulsive not, perfectionism and control Categorical Models of PD (2) Strengths of categorical model: Clinical utility - Easier to communicate with other clinicians - Easier to refer to previous experience - Can manualise treatment Research utility - Can group patients for outcome studies - Can develop research into prognosis and aetiology with homogeneous groups Categorical Models of PD (3) Weaknesses of categorical model: Polythetic system (all diagnostic symptoms carry the same weight) High heterogeneity High co-occurrence of PDs with other disorders Reliability Dimensional Models of PD (1) Dimensional Model - Alternative model presented in the DSM-5 for future consideration (Skodol et al, 2015) - Allows for varying degrees of impairment or severity - More suited for conditions where there is a continuum ranging from healthy to unhealthy Dimensional Models of PD (2) Primary alternatives proposals for a dimensional classification of PD are: Dimensional classification of existing categories Dimensional Assessment of Personality Pathology (DAPP) Schedule for Nonadaptive and Adaptive Personality (SNAP) The three polarities of Millon The seven-factor model of Cloninger The Five Factor Model (FFM) Dimensional Models of PD (3) Strengths of dimensional model: Reliability Greater accuracy and precision Eliminates the need for vague diagnoses such as ‘Other Specified’ and ‘Unspecified Personality Disorder’ Dimensional Models of PD (4) Weaknesses of dimensional model: Model too complex for clinical practice Agreement is poor if used to generate categorical diagnoses By one count, there are 18 alternate proposals for a dimensional classification of PD; which one should be used? Assessment (1) Clinical interview, look for: - symptoms dating from adolescence/early adulthood, not occurring solely in the presence of another disorder e.g. depression or anxiety - Significant difficulties in interpersonal interactions - Assessment (2) Banerjee et al (2009) Advances in psychiatric treatment Take home messages 1. Personality exists on a spectrum therefore the current categorical classification system is viewed by many as limited and/or inappropriate 2. Current theories on the aetiology of personality disorders are taking a lifespan approach 3. Assessment should particularly focus on: - risk of harm to self and others - comorbidities - the complexity of a person’s personality difficulties - the impact on carers/family members and service needs Post-session activity (1) Narcissistic Personality Disorder? Post-session activity (2) Question Personality disorders (particularly borderline PD) are a controversial diagnosis Why do you think borderline personality disorder is so controversial? Post-session activity (3) Diagnostic overlap How would you differentiate between borderline personality disorder and bipolar disorder? Associate Professor, Sarah Rowe, Division of Psychiatry, UCL Clinical Mental Health Introduction to Personality Disorders (PDs) (Part 2) Learning Objectives To critically appraise different approaches to treatment and management of PDs To gain an understanding of service user experiences of community PD services Treatment (1) Primary treatment is psychological or psychosocial intervention Medication used despite lack of evidence to support their use in PDs. Should only be used in combination with psychosocial intervention Most of the evidence focuses on treatment for BPD Bateman et al., 2015 Treatment (2) Psychological Therapies - Dialectical Behaviour Therapy (DBT) o Teaches skills in the areas of mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness - Mentalisation Based Therapy (MBT) o Mentalisation is the ability to think about thinking. This means examining your own thoughts and beliefs, and assessing whether they're useful, realistic and based on reality - Schema Therapy o Blends CBT, Attachment, Psychodynamic and Emotion-focused therapies - Psychodynamic Therapy o Focuses on unconscious processes as they manifest in a person’s present behaviour Treatment (3) Therapeutic Community Treatments - A place where people with long-standing emotional problems can go for weeks or months - Mostly group work - People learn from getting on – or not getting on- with other people in the group. Disagreements or upsets happen in a safe place - People in treatment have a say over how the community is run - In the UK it is more common for this treatment to be offered as a day programme, 5 days a week - Treatments and populations are so varied that results are difficult to interpret Treatment (4) Medication Antipsychotics (usually at a low dose) can reduce suspiciousness in Cluster A disorders Antidepressants can help with mood and emotional difficulties in Cluster B disorders SSRI’s and mood stabilisers can help to reduce impulsivity and aggression in borderline and antisocial PD Can reduce anxiety in Cluster C disorders Safer Care for patients with PD – report, Feb 2018 Services involved in support & treatment Community Mental Health Teams (CMHT) – provides day-to-day support and treatment, while ensuring as much independence as possible. May include Social Workers, Nurses, Pharmacists, Psychologists, Psychiatrists, Occupational Therapists Crisis Resolution Teams (CRT) – Supports those experiencing an acute psychiatric crisis which would otherwise require hospitalisation Specialist PD services – A day patient service specialising in the management and treatment of people with personality disorders e.g. Maudsley. Provides individual and group therapy within the framework of a therapeutic community Service user experiences of community services for PD Service users wanted a long-term perspective on treatment to support improvement over several years Therapies often did not address past traumas or day-to-day problems Good relationships from clinicians who convey hope about long-term improvement is key Services need to have more focus on social and practical difficulties More training needed for clinicians working outside of specialist PD services Sheridan-Rains et al., 2021 https://doi.org/10.1371/journal.pone.0248316 Take home messages 1. Psychosocial treatment for PDs shows promise but studies on treatment approaches are limited by their focus on BPD 2. Medication is often prescribed to people with personality disorders despite their not being good evidence for its effectiveness 3. Services and training for non-specialist staff need to be co-designed with service users and should include trauma informed care Considerations for the future Should personality disorders be renamed? - Complex Emotional Needs - Emotional Regulation Disorder What is the optimal length of time for psychological therapy? Will we see a rise in the diagnosis of Emerging PD with the introduction of the ICD-11? Does personality change? E.g. head injury or antidepressant use Other relevant reading Diagnosis and classification of personality disorders: novel approaches. Mulder and Tyrer (2019). Curr Opion Psychiatry: 32, 27-31 Mental Elf blogs (personality disorders) https://www.nationalelfservice.net/mental-health/personality- disorder/ including the following blogs: Bordering on the bipolar: a review of criteria for ICD-11 and DSM-5 persistent mood disorders. Luty (2019). BJPsychAdvances. 54 Safer care for patients with personality disorder (report), Feb 2018. Services for people with diagnosable personality disorder, position statement Royal College of Psychiatrists Position Paper, Jan 2020 Associate Professor, Sarah Rowe, DivisionClinical Mental Health of Psychiatry, UCL Introduction to Personality Disorders (PDs) (Part 3) Learning Learning objectives Objectives To discuss the ethics and controversy around PD diagnosis To reflect on challenges of diagnostic overlap between PDs and other psychiatric disorders To consider the clinical and social aspects of PDs through the lived experience of a person with BPD Narcissistic Personality Disorder? Question Personality disorders (particularly borderline PD) are a controversial diagnosis Why do you think borderline personality disorder is so controversial? BPD controversy Lots of debate about classification Poor construct validity and reliability Misdiagnosis is high One of the most stigmatising mental health diagnoses Many people with this diagnosis have histories of abuse. Are we pathologising their response to trauma? PD vs Other Psychiatric Disorders (1) How can you tell the difference? BPD vs Bipolar (Paris & Black, 2015) BPD vs Complex PTSD (Cloitre et al., 2015) OCPD vs OCD (Mancebo et al, 2005) AVPD vs Social Phobia Why does it matter? PD vs Other Psychiatric Disorders (2) To main things to consider: 1. Are they two distinct disorders that co-occur? 2. Are the similar, overlapping constructs that should be on a continuum? PD vs Other Psychiatric Disorders (3) Example: Borderline PD Bipolar Affective instability Patterns of depression & mania Impulsivity Impulsivity Unstable relationships & Self-doubt, sense of guilt, self-image low-self-esteem Suicidal behaviour/self- Suicidal thoughts harm Dysphoria, feelings of Depression, feelings of hopelessness worthlessness PD vs Other Psychiatric Disorders (4) How would you differentiate between borderline personality disorder and bipolar disorder? Differentiating signs/symptoms: - mood disorder sx develop over PD vs Other much shorter periods of time Psychiatric and represent a change in functioning e.g. insomnia, Disorders weight loss (5) - Moods in PD are usually reactive to interpersonal events or internal experiences PD vs Other Psychiatric Disorders (6) ICD-11 PTSD ICD-11 COMPLEX PTSD DSM-5 BPD Re-experiencing, Re-experiencing, Frantic effort to avoid flashbacks, nightmares flashbacks, nightmares abandonment Avoidance (thoughts, Avoidance (thoughts, Unstable relationships people, places, activities) people, places, activities) Sense of threat Sense of threat Unstable sense of self Hypervigilance, startle Hypervigilance, startle Impulsiveness Emotion regulation Self-harm (anger, hurt feelings) Negative self-concept Mood changes (feelings of worthlessness or guilt) Interpersonal problems Chronic feelings of (not feeling close, emptiness disconnected) Intense anger (Cloitre et al., 2014) Paranoid/dissociation PD & Autism Interview with Jeantique (she/her) Has used mental health services since teens Diagnosed with BPD >5 years ago Here to share her lived experience of BPD, start conversations and challenge the stigma attached with the disorder Culture and Diversity in Mental Health Practice Christiana Joseph - Slides adapted from Henrietta Mbeah-Bankas Objectives Explore the concept of culture and diversity. Establish implications for health care; legal, ethical and clinical Explore our own attitudes and perceptions (including personal biases) of different groups within society and how these might influence our interactions with individuals or members of that group. Understand the impact of working with different cultures and diverse individuals N.B We will cover slides 1-31 today. Slides 35 to 48 are for guided post lecture consolidation Culture A shared system of meaning, it derives from common rituals, values and laws, and provides a common lens for perceiving and structuring reality for its members (Veroff and Golderberg1995). The total of non-biologically inherited patterns of shared experience and behaviour through which personal identity and social structures are attained in each generation in a particular society, whether ethnic group or a nation (Littlewood 1990) Characteristics of culture Culture is neither a static or monolithic phenomenon; that is there may be considerable variation within cultural groups, this variation being affected by variables such as social class, geographic location, or generational status Culture operates at an unconscious level-unconscious bias It constructs us and we construct it- it is dynamic It constructs many of our basic notions; such as self, body, emotions and ideas about health and illness Malik 2000 Diversity Diversity is present when there is a mixture of differences in age, religion, culture, gender, ethnicity, education and more amongst a group of people within the same environment. What are some of the pros and cons of diversity? Protected Characteristics What do you understand by the term ‘Protected Characteristics’ and what legislation(s) underpins this protection? Thinking about cultural values, how may this be linked with ‘protected characteristics? Legal: Equality Act 2010 An individual or organisation that provides services to the public must not treat someone worse just because of one or more protected characteristic; Age Disability Gender reassignment Pregnancy and maternity (which includes breastfeeding) Race Religion and belief Marriage and civil partnership Sex Sexual orientation Equality and Human Rights Commission - Protected characteristics Ethics and Morals Is there a difference between Ethics and Morals? Ethical: 4 Universal Principles Universal principles Respect for autonomy Beneficience Non-Malficence Justice Beauchamp, T. L. and Childress, J. F (2001) Ethical The healthcare provider: Universal principles assumes the patient has capacity to make rational, informed Respect for autonomy and voluntary decisions. basis for the practice of "informed consent" Beneficience Non-Malficence Justice Beauchamp, T. L. and Childress, J. F (2001) Ethical The healthcare provider: Universal principles Respect for autonomy has an obligation to convey benefits and to help patients to Beneficience further their legitimate interests Non-Malficence Justice Beauchamp, T. L. and Childress, J. F (2001) Ethical The healthcare provider: Universal principles Respect for autonomy Beneficience does not intentionally create a harm or injury to the patient, Non-Malficence either through acts of commission or omission. Justice Beauchamp, T. L. and Childress, J. F (2001) Ethical The healthcare provider: Universal principles Respect for autonomy Beneficience Non-Malficence Allocates (scarce) resources in a fair way. Justice Beauchamp, T. L. and Childress, J. F (2001) Interactive Workshop Look at the following slides/photos Using you mobile phone, go to Mentimeter.com and use the code… Please answer the questions You have 3 minutes ALI John Jane Martin Bias What is Bias ? ‘Bias is a prejudice in favour of or against one thing, person, or group compared with another usually in a way that’s considered to be unfair. Biases may be held by an individual, group, or institution and can have negative or positive consequences.’ (Office of Diversity and Outreach, University of California, 2021). Kahneman (2011) distinguishes between two types of thinking i.e. system 1 and system 2. Unconscious Bias ( Implicit ) – System 1 type of thinking which we are not aware of (Greenwald & Krieger, 2006) Conscious Bias ( Explicit ) – System 2 type Clinically why is a conscious appreciation for culture and diversity important? Addressing Unconscious/Conscious Bias A - Acknowledge C - Challenge T – Train ( iHASCO Unconscious Bias Training ) ‘Pay attention to what’s actually happening beneath the judgements and assessments Acknowledge your own reactions, interpretations, and judgements Understand the other reactions, interpretations, and judgements that may be possible Search for the most empowering, productive way to deal with the situation Execute your action plan’ ( Ross, 2014 ) Implications for mental health We live in a multicultural society People who experience discrimination in social or economic contexts have a higher risk of poor mental wellbeing and developing mental health problems; People may experience inequality in access to, and experience of, and outcomes from services; and Mental health problems result in a broad range of further inequalities. Implications for mental health (cont’d) Ethnic Minorities suffer poorer health, poorer access and poorer outcomes compared to their white counterparts Black African women had a mortality rate four times higher than White women in the UK. There is a significant disproportionate number of ethnic minorities detained under mental health legislation in hospitals in England and Wales – Black African women were seven times more likely to be detained than White British women. Gypsies, Travellers and Roma were found to suffer poorer mental health than the rest of the population in Britain. They were also more likely to suffer from anxiety and depression. https://www.equalityhumanrights.com/en/britainfairer-report/supporting-evidence Intersectionality Intersectionality broadly derives from the premise that people have multiple, shifting and layered identities, It recognises that when two or more elements of an individual’s identity (including age, disability, gender and gender identity, race, religion or belief, and sexual orientation) simultaneously interact, They become inseparable and this, coupled with social determinants, economic status and broader context, create a unique and distinct experience. "Intersectionality is a framework for conceptualizing a person, group of people, For example: or women Black African socialwere problem seven timesas affected more likely to be by a number detained of under mental discriminations and British health legislation than White disadvantages. women. It takes into account people’s overlapping identities and experiences in order to understand the What are the elements of intersectionality in this scenario? complexity of prejudices they face." -YW Boston Practitioners’ skills Listen to the person and engage in a dialogue Self awareness Be sensitive to religious issues Avoid pathologising, dismissing or ignoring the religious or spiritual experiences of service users. Explore the explanatory model of the patient and clinician Take risks, don’t be afraid to ask Show a level of curiosity; “want to” not “have to” Practitioners skills cont’d Help service users identify those aspects of their lives that provide them with meaning, hope, value and purpose. Provide good access to relevant and appropriate religious and spiritual leaders. Need to be educated, use of “culture broker”. Read about culture. Look for the difference that makes a difference Take an intersectional approach (Cornah 2006) Practitioners' Barriers Lack of time. Concern about stepping outside one’s area of expertise. Discomfort with the subject. Worries about imposing beliefs on the service user. Lack of interest or awareness. Lack of training. (Cornah 2006) Service Users Barriers Interest by Ethnic Minority communities Availability of BAME staff within mental health services Language difficulties Racism of staff Cultural awareness amongst staff Lack of government interest Walls and Sashidharan (2003) Contributory factors Services are perceived as culturally insensitive and discriminatory. Experience and expectation of racist mistreatment discouraging early access. Mental health problems remains a taboo for a lot of BAME communities. Health and illness belief models. Helman (2000) Islam et al 2015. Example: Watch Dementia services in Tower Hamlets (from min 1.23) https://www.youtube.com/watch?time_continue=355&v=xG zyYEps-bw&feature=emb_logo What were some of the culturally sensitive approaches that they used? Ethnocultural transference and Countertransference Transference: the redirection of feelings onto someone else (e.g. the therapist). Countertransference: the redirection of a therapist's feelings toward the client. Ethnocultural transference and Countertransference “Aziza applies for therapy at an outpatient Amsterdam mental health clinic. At a therapy session, she later says, «Anything less than the very best is unacceptable to me. It really has to do with the fact that I grew up Moroccan here in the Netherlands.» At primary school for example, her teachers advised her to attend a simple four-year secondary school. Now she is working at a high level in the field of management. Due to her fear of not getting the treatment she deserves, at the intake interview she is already standing her ground. The therapist finds her a bit aggressive. Her behaviour feels suspicious, intimidating and transgressive, and irritates the therapist, perhaps also because his own natural experience of being in the mainstream Dutch majority position fails to give him much familiarity with and sensitivity to people like Aziza and her type of behaviour in a situation of assessment and selection. A consequence of the therapist’s irritation is that Aziza stands her ground even more and the therapist feels even more annoyed and so on. His growing irritation makes the therapist less able to use his psychoanalytical stance of empathy and understanding and he reverts back to his basic diagnostic skills as a psychiatrist or clinical psychologist. Aziza’s behaviour is subsequently seen as a sign of serious personality pathology (paranoid, borderline, narcissistic). This is why Aziza’s therapy prognosis at first is assessed as rather poor, which is a self-fulfilling prophecy. “ Gomperts 2018 Ethnocultural transference and Countertransference Comas-Diaz and Jacobsen (1991) Inter-ethnic transference Intra-ethnic transference Over-compliance and Omniscience-omnipotent friendliness therapist Denial of ethnicity and The traitor culture The autoracist Mistrust, suspicion and Ambivalence hostility Ambivalence Ethnocultural transference and Countertransference cont’d Comas-Diaz and Jacobsen (1991) Inter-ethnic Intra-ethnic countertransference countertransference Over-identification Denial of cultural differences Us and them Guilt Distancing Pity Cultural Myopia (Short sightedness) Aggression Anger Ambivalence Survivor guilt Hope and despair Summary Listen- patients perception of problem Explain–professional perception of problem Acknowledge- similarities and differences between perceptions Recommend- recommendation with client involvement Negotiate- treatment plan Berlin and Fowkes (1982) in Campinha-Bacote 2011 Conclusion Engaging and working effectively with individuals from diverse backgrounds in a non-discriminatory way Includes, but also goes beyond exploring issues of culture and ethnicity It involves treating people as equals It is about connecting with people References Beauchamp, T. L. and Childress, J. F (2001) Principles of Biomedical Ethics. 5th ed. Oxford University Press, Oxford. Berlin and Fowkes (1982) in Campinha-Bacote, J. (2011) Coming to know cultural competence: An evolutionary process. International Journal of Human Caring. 15 (3) 42-48 Comas-Diaz, L. and Jacobsen, F. M (1991) Ethnocultural transference and countertransference in the therapeutic dyad. American Journal of Orthopsychiatry 61(3). Cornah, D. (2006) The impact of spirituality on Mental Health. London: Mental Health Foundation. FitzGerald, C. and Hurst, S (2017) Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics (2017)18:19 DOI 10.1186/s12910- 017-0179-8 Health Education England (2019) The Topol Review, Preparing the healthcare workforce to deliver the digital future. London Helman, C. (2000) Culture, Health and Ilnness. Butterworth Heinmann. Islam, Z.; Rabiee, F. Singh, S. P (2015) Black and Minority Ethnic Groups’ Perception and Experience of Early Intervention in Psychosis Services in the United Kingdom Journal of Cross-Cultural Psychology. DOI: 10.1177/0022022115575737 Littlewood, R. (1990) From Categories to Contexts: A decade of New Cross-Cultural Psychiatry. British Journal of Psychiatry 156, 308-327 Malik, R. (2000) Culture and Emotions: Depression among Pakistanis In Squire, C. (eds) Culture in Psychology. London: Routledge. Owen, S. And Khalil, E. (2007) Addressing diversity in mental health care: a review of guidance documents. International journal of Nursing studies 44.pp467-478 Veroff, J. B. and Goldberger, N. R. (1995)What’s in a name In Goldberger, N. R. and Veroff, J. B. (eds) The Culture and Psychology Reader. New York: New York University Press. Walls, P. and Sashidharan S.P. (2003) Real Voices: Survey Findings from a Series of Community Consultation Events Involving Black and Minority Ethnic Groups in England. London: Department of Health. Introduction to DBT: Principles and Practice Dr Eugenia Drini Senior Counselling Psychologist Clinical Lecturer in Mental Health Sciences UCL Division of Psychiatry Overview What is Dialectic Behaviour Therapy (DBT) Borderline Personality Disorder-Diagnosis and Formulation Key principles of DBT-Structure of Treatment Overview of DBT Skills Practice What is DBT? A form of Cognitive Behaviour Therapy (CBT) Developed by Marsha Linehan in 1993 to treat clients diagnosed with borderline personality disorder (BPD) who were chronically struggling with suicidal ideation More recently Dr. Linehan shared that she struggles with BPD Focuses on increasing an individual’s ability to cope with intense emotions in more ‘adaptive’ ways and improve their quality of life Recommended by the National Institute for Health and Care Excellence (NICE) ‘WHY’ DBT? CBT did not work for clients with chronic suicidality and BPD – Change focus was ‘invalidating’ – DBT seeks to balance working with the person to change behaviours with acceptance of the person where they are Solutions: Validation, Dialectics, Multi-modal treatment Effectiveness of DBT for BPD DBT has been found to reduce – Suicidality – Parasuicidal behavior – Treatment drop-out – Hospitalisations – Substance Use – Depression, Hopelessness, Anger DBT has also been found to provide an effective way to reduce staff burnout Other Adaptations of DBT Substance Use Adolescents/Children Binge Eating Bipolar Disorder Couples Inpatient Borderline Personality Disorder Assessment and Case Conceptualisation through DBT lens What is Borderline Personality Disorder? Main Symptoms of BPD Emotional instability/’dysregulation Disturbed patterns of thinking or perception – "cognitive distortions" or "perceptual distortions“ Impulsive behaviour Intense but unstable relationships with others Identity Disturbance Considerations around BPD Diagnosis Comorbidity: can be better understood as related to psychosis, depression, to bipolar disorder or anxiety disorders, or to other impulsive disorders. Stigma: ‘Untreatable’, ‘Difficult’, ‘lacking willpower’ ‘Problematic personality’-who you are VS Biological Illness-what is your diagnosis: incorporated into their identity Aetiology What causes BPD? Biological and environmental factors account for BPD Born with emotional vulnerability Growing up in ‘invalidating’ environments Reciprocal influences between biological vulnerabilities and an invalidating environment lead to a dysfunction in the emotion regulation system Development of BPD Linehan's Biosocial Theory ‘Invalidating environment’: an environment where one’s emotions and struggles get ‘trivialised’, disregarded, ignored, or punished 'Non-extreme' efforts to get help get ignored Only extreme communications/behaviours are taken seriously Why? parents are cruel (invalidated or abused as children) low empathy and skill: don’t understand child’s struggle- intergenerational pattern of BPD Sexual abuse Development of BPD Linehan's Biosocial Theory As a result clients with this diagnosis learn to 'invalidate' themselves Transactional model with individual vulnerability interacting with the invalidating response and vice versa Vicious Cycle: Invalidation increases emotional arousal, likely leading to more invalidation Clients become intolerant of their own emotions and struggles (punish, suppress, and judge their emotions) Clients easily feel invalidated by others They learn to influence/communicate with others through extreme behaviours They might engage in self-injury/’parasuicidal’ behaviours to get help or.. They may use aggression, self-injury, and suicidality to distance others Core Problem: Emotion Dysregulation 1. Emotional sensitivity (easily triggered/no 'emotional skin’) 2. Emotional intensity 2. Slow return to baseline (recovery) Desperate attempts to escape emotions through 'maladaptive ways' (e.g. self-harm/suicide/substance use/binge eating) Staff Burnout and Stigma around BPD Professional discourses around ‘manipulation’ Boundaries Key principles of DBT Components of a DBT Program 1. Individual (DBT) Therapy 2. Weekly Skills Training Group 3. Phone Coaching 4. DBT Consult DBT-informed Therapy: - Any treatment that does not include ALL FOUR of the above components - E.g. CBT therapy that incorporates some DBT skills - Group only Skills Training - Skills Group + Individual Therapy without Phone Coaching - Skills Group, Individual Therapy, Phone Coaching but no consultation team Key principles of DBT ‘Dialectical’-Acceptance & Change DBT is ‘dialectical’ Dialectical is about walking the middle path between the extremes For everything there exists an opposite-in dialectics both views can be true (e.g. we need to accept the client for where they are, but they also need to change to have a life worth living) Key principles of DBT ‘Behaviour’ DBT is a behavioural therapy DBT uses strategies to increase new behaviours in ourselves and the clients, such as ‘reinforcement’ and to decrease behaviours such as ‘extinction’ ‘Therapy’ Individual therapy is collaborative and tailored to the person’s needs Skills training is delivered in a group setting and is ‘didactic’ Therapeutic relationship is central in DBT: “with a highly suicidal patient, the relationship with the therapist is at times what keeps her alive when all else fails” (Linehan, 1993) Self-disclosure “Not much DBT can be done before this relationship is developed” (Linehan, 1993) Overview of DBT Strategies and Skills Individual Therapy: Validation Chain Analysis Groups: Distress Tolerance Interpersonal Effectiveness Emotional Regulation Mindfulness Validation Recognises how well founded a person’s response is to something, given their circumstances Communicates to the other person they are understood, even if we don’t agree with their stance Active listening, reflection, accurate summaries Chain Analysis A detailed description of the chain of events that led to the ‘problem behaviour’ Description of the prompting event Description of the chain of events that followed What were the consequences of the behaviour Chain Analysis Group Skills Distress Tolerance Distress tolerance skills enable being able to survive crisis and distress without making things worse Distraction, self soothing Interpersonal Effectiveness Interpersonal effectiveness skills enable us to develop effective relationships and to achieve what we need in our relationships Core to this is obtaining our objectives while also maintaining relationships and self-respect Skills that aim to help clients communicate their needs in more effective ways Emotional Regulation Emotional regulation enables the reduction of emotional suffering It is not about getting rid of emotions but understanding and changing how we feel Understanding and naming emotions Changing unwanted emotions by: Checking the facts: Is it our interpretation of events or events themselves causing emotional difficulties Opposite action to emotion if not effective (e.g. walking away when angry) Mindfulness Watch video and try to answer the following questions https://www.youtube.com/watch?v=BXWk6h3A0Bw 1. What clinical features of BPD do you observe in the video? 2. Which DBT skills you might use to help this person? 3. What challenges do you think you might experience in working with this client and how would you tackle them? 4. What might the day-to-day challenges of living with this condition? Further information about DBT and BPD Alma Johnston is an expert by experience and has a personal blog writing about her experience of living with BPD https://bpdlifeinthemoment.blogspot.com/ Link to updated PDF of latest DBT research: https://behavioraltech.org/evidence/ THANK YOU! Any Questions? A brief history of mental health care – from asylum to community Moodle talk for the MSc Clinical Mental Health Sciences – Clinical Mental Health Module Prof Sonia Johnson UCL Division of Psychiatry Content The asylum and its decline Why, how and with what effect deinstitutionalisation has taken place in the UK Mental health care in England – early history Until the 18 century: Religious model th (demoniacal possession) predominates 1377: first institution dedicated to the care of the mentally ill: St Mary of Bethlehem 18th century: Psychiatry develops as a profession, madness starts to be seen as treatable Some charitable hospitals “Trade in lunacy” – confinement for profit. 1774 Madhouse Bill in response to concern re families having sane people confined “Single lunatics” imprisoned at home – Mrs Rochester in Charlotte Bronte’s Jane Eyre Why were the large asylums opened? Concern about “criminal lunatics”, especially following assassination attempt against the King in 1800 Therapeutic optimism – ‘moral treatment’ advocated respect, purposeful activity. Concern about conditions & lack of regulation in private madhouses and for “single lunatics” The end of ‘outdoor relief’ under the Poor Law – mentally ill accumulate in workhouses Social control – mental illness harder to tolerate in an urban industrialised society (Foucault) 1845: The County Asylums Act: every county obliged to open an asylum The 1850s to the 1950s: the era of the asylum From the 1850s: loss of optimism about treatability Interest in eugenics – segregate mentally ill to prevent genetic defects Deteriorating conditions with repeated scandals about treatment, high mortality rates Overcrowding – e.g. Friern Barnet built for 1,000 – housed 2,000 Rubery Hill Hospital 1876-1993 1,000+ inmates at peak, many incarcerated for many decades Pig farm, industrial therapy workshops “Northfield experiments” in WW1 Weekly dances, concerts, theatre 1949 – enquiry regarding wrongful certifications Psychiatric hospital populations in England 1857: 15,000 in 41 county asylums (plus 180 private madhouses) 1867: 25,000 in county asylums 1890: 120,000 in county asylums. Little private sector provision. 1954: 152,000 in 130 large Victorian psychiatric hospitals Following this – progressive decline over 50 years Enoch Powell’s “Water Tower” speech in 1961: most asylums to close by end of 1970s. 1993: 39,500 in psychiatric beds, of which 52% in large Victorian hospitals. 38 out of 130 large hospitals closed. 2002: 34,000 mental illness beds. Approx 110 out of 130 asylums closed. 2010: 22,000 mental illness beds 2019: 18,000 More than half a century of deinstitionalisation – what was the impetus? Financial, especially in the US New drugs – chlorpromazine in 1950s Evidence and arguments regarding ill effects of institutionalisation Humanitarian concern about the mentally ill, especially following murders under the Nazis and scandals in many European countries Anti-psychiatry movement Better structures for community care with the advent of the welfare state – NHS funding for care outside hospital, benefits Asylum closures Corridors at High Royds asylum, Yorkshire TAPS study (Leff et al): planned discharge from 2 asylums of 670 patients, most to supported residential services Few adverse outcomes over 5 years Little clinical or social change Clear preference for community living Middlesex County Lunatic Asylum (Friern Barnet Hospital) in 2018 Fig. 2 Homicide rates in England and Wales, 1946-2004. Homicide rates among people with mental illness show no signs of having risen during deinstitutionalisation Large, M. et al. The British Journal of Psychiatry 2008;193:130-133 Copyright © 2008 The Royal College of Psychiatrists The move out of the asylum – where are we now? Most though not all asylums closed, long-stay beds radically reduced Most people with long-term mental health problems have no need for long stays in hospital and markedly prefer community living Deinstitutionalisation is safe, in the UK and elsewhere. BUT Inpatient bed use still at higher end of European spectrum, especially for detained patients. Rate of people being compulsorily admitted under Mental Health Act has been rising, and beds for emergency admission are in short supply. We don’t know much about the long-stay residential placements replacing many beds – has been described as “reinstitutionalisation” (see Helen Killaspy’s QUEST study) The functions of the asylum need to be comprehensively replaced, including occupation and social contact – not clear they have been. Deinstitutionalisation beyond the UK Closure of large asylums and development of community care is a WHO priority worldwide In high income countries: progress made in most countries towards closure of large hospitals. Community care developed to various degress Middle and lower income countries: also generally policy – but in 2014 WHO notes most lower income countries spent vast majority of mental health resource on hospital care. Introduction to bipolar disorder Sonia Johnson Preliminary talk for the Clinical Mental Health Module Learning outcomes To be able to identify the main features of bipolar affective disorder To be able to describe the impact on people’s lives of bipolar affective disorder. To be familiar with basic evidence on aetiology and epidemiology of bipolar disorder. Bipolar affective disorder Also called manic depressive illness Episodes of both depression and of elevated mood, usually interspersed by stable mood. Most people who have manic episodes also have depressive ones. Depression is similar to in other contexts - not necessarily very severe Epidemiology Lifetime: Around 1% prevalence diagnosed bipolar disorder. Similar figures worldwide “Bipolar spectrum” including milder undiagnosed presentations (“Bipolar II)– maybe up to 5-6%. Onset: first diagnosis – median age early 20s. Often some evidence of unstable mood before then. Elevated mood (1) - Hypomania Persistent elevation of mood – elated/expansive/irritable Increased energy, activity, sociability Increased feeling of wellbeing Disinhibition, increased libido Euthymia Decreased sleep and need for sleep (normal mood) Decreased concentration More talkative & speech pressured Hypomania Perceptions more vivid than usual New ventures and mild overspending May interfere with work& social life, but normal Mania activities and routines continue to a degree Depression and hypomania only – Bipolar 11 (DSM V) Mania with psychotic symptoms Elevated mood (2) Mania More severe than hypomania Pressure of speech severe – uninterruptible Flight of ideas – rapid jumps between topics, connections often unusual e.g. puns, rhymes Very disrupted sleep/not sleeping at all Euthymia Restlessness and agitation Loss of inhibitions and impulse control Hypomania Disregard of risk Grandiose ideas Mania Irritability and aggression, occasionally violence 1 week duration, complete disruption of Mania with psychotic work and social life symptoms Mania with psychotic symptoms Psychotic symptoms occur in about 2/3 people with mania Euthymia Characteristically: In keeping with elevated mood Grandiose delusions, persecution because of Hypomania special abilities/missions Second person auditory hallucinations Mania Once mania is severe, insight is rare Mania with psychotic symptoms Hypomania “When you’re high, it is tremendous. The ideas and feelings are fast and frequent like shooting stars, and you follow them until you find better and brighter ones. Shyness goes, the right words and gestures are suddenly there, the power to captivate others a felt certainty. There are interests found in uninteresting people. Sensuality is pervasive and the desire to seduce and be seduced irresistible. Feelings of ease, intensity, power, well-being, financial omnipotence and euphoria pervade one’s marrow.” Kay Redfield Jamieson - An Unquiet Mind (1996, Picador) The transition to mania and its aftermath “But somewhere, this changes. The fast ideas are far too fast, and there are far too many; overwhelming confusion replaces clarity. Memory goes. Humour and absorption on friends’ faces are replaced by fear and concern - you are irritable, angry, frightened, uncontrollable. Finally there are only others’ recollections of your behaviour - your bizarre, frenetic, aimless behaviour - for mania has at least some grace in obliterating memories. ….. Credit cards revoked, bounced cheques to cover, explanations due at work, apologies to make, intermittent memories (what did I do?), friendships gone or drained, a ruined marriage.” Risks in bipolar disorder At extreme: severe recklessness due to beliefs about physical invulnerability/special powers More frequently: Spending Socially disinhibited behaviour (work/social life) Sexual disinhibition Reckless new ventures Dangerous driving Physical risk taking e.g. in sport Living with bipolar disorder Large majority of people live uneventfully in community most of the time. Most people recover well between episodes, but around 10-20% remain significantly unwell. Compatible with high functioning – bipolar lawyers, doctors, clinical psychologist, bankers etc. Comorbid drug and alcohol problems and anxiety, social damage from mania impact on functioning Employment rate: 30-50% Does it make you artistic? Thought to have bipolar disorder: Writers: John Clare, Emily Dickinson, Hemingway, Strindberg, Virginia Woolf, Byron, Goethe, Patricia Cornwell, Painters: van Gogh, Goya Composers: Donizetti, Handel, Klemperer, Mahler, Schumann Performers: Stephen Fry (??), Vivien Leigh, Carrie Fisher, Richard Dreyfus, Tony Slattery. Maurizio Pollini, Spike Milligan, Catherine Zeta Jones 10-20% writers, artists seemed to suffer from BPAD in biographical study Kay Redfield Jamison – “Touched by Fire” Probably true to an extent – though many with bipolar more disorganised than creative. Risk factors Considerable genetic component: 67% risk for twins, 15-20% for children of a parent with bipolar disorder Life events - triggers for individual episodes Can begin after childbirth, high risk of recurrence post-natally Organic mania, especially if late onset. Hormonal causes, taking steroids, stimulants. Some psychological risk factors found: E.g. rigid black/white thinking Over-sensitivity to disruption of routines Differs from most psychiatric disorders in not having clear & substantial social risk factors Prognosis Much more time in depressive than manic episodes (5% vs. 20%) Suicide a risk in depression – overall rate around 20 times greater than general population Increasingly depressed rather than manic as get older Worse prognosis with: Early onset Comorbidities: drug and alcohol problems, anxiety, personality disorder Some people function very highly Introduction to Compassion Focused Therapy Dr Carmen Chan Clinical Psychologist and Service Lead Horizon (Supporting Young People and Families Affected by Sexual Harm) Calm minds think differently Dr Deborah Lee Acknowledgements Dr Deborah Lee Berkshire Traumatic Stress Service Everybody I’ve ever worked with What makes a good life? Good relationships make us happier and healthier Social connections are good for us and loneliness kills It’s the quality of your close relationships that matters Good relationships protect our bodies and our minds https://www.ted.com/talks/robert_waldinger_what_makes_a_good_life_lessons_from_the_lon gest_study_on_happiness Group discussion How much of our life do we dedicate to this? How much towards other pursuits? How much of our work is focused around this? Or, do we focus on ‘what’s wrong’? What understanding do we want to bring to our work? Compassion - What is it? “A sensitivity to the suffering of self and others (and its causes), with a commitment to relieve and prevent it.” Prof Paul Gilbert Understanding the development of the human brain Humans are an evolved species Symbolic thoughts and sense of self, mentalization, theory of mind, metacognition (approx 2 million years ago) Caring/affection, group, alliance-building, play, status (approx 120 million years ago) Territory, aggression, sex, hunting (approx 500 million years ago) With thanks to Dr Deborah Lee Trickiness of the human brain All parts embedded in each other End up speaking ‘different language’ ‘Old’ reptilian/limbic brain takes over in times of threat ‘New’ (thinking’) brain turns off Main motivation: SURVIVAL Our only responses under threat … F FIGHT A APPEASE (friend) F FLIGHT/FLEE F FREEZE F FLOP THIS IS NOT OUR FAULT What keeps us feeling safe? Internal safeness External safeness Balanced mind Drive Compassion Threat Shame Imagine I’m going to ask you to do the following: Close your eyes Think about something you don’t want anybody else to know about you I’m going to around an tap one person on the shoulders That person will have to say that thing out loud to the group Reflection: Feeling in body? Thoughts? Do? Shame Physiology External threat Shame Internal threat Safety strategies Humans are social beings Compassio n Drive Threat FAFFF-ing becomes our daily response F FIGHT A APPEASE (friend) F FLIGHT/FLEE F FREEZE F FLOP Compassion is an antidote A sensitivity to the suffering … with a commitment to of self and others (and its relieve and prevent it causes) … We will all experience pain Why do we Circumstances and context are often not our fault need it? Unfortunately, we often experience this pain as something being wrong with ourselves This is not your fault … This is just one version of me Problems are solutions to other problems ‘problem behaviour’ Attempted Attempted solution solution ‘problem’ behaviour … but it is your responsibility Main aim of Compassion Focused Therapy To create emotional strength and courage to create a felt sense of psychological safeness To respond to threat with non-judgement and self- acceptance To tolerate and experience emotions Personal growth through adversity Process of Compassion Focused Therapy Developing a therapeutic relationship Compassionate understanding Mindful awareness and developing acceptance of compassion Working through barriers to experiencing compassion Compassionate practice Integrated Self-soothing memories talk Compassionate Compassionate perspectives feelings Compassion flow exercises Compassion Compassion Compassion flowing into flowing out flowing in self What’s stopping you from taking the ‘road less travelled’? Fear of compassion It’s about self pity It’s about being selfish or self centred I don’t deserve compassion My needs are not as important as other people’s It’s about letting yourself off the hook It’s a weak or soft option It will set me up for a fall It’s about stopping feeling other emotions It will be too hard and overwhelming Emotional obstacles Environmental obstacles With thanks to Dr Deborah Lee I took the one less traveled by, And that has made all the difference Committing to a life with compassion Intimate Family Friends Hobbies relationships Personal Personal Work Contributions growth welfare Other Making a compassionate commitment I want to maintain this because ___________________ What can you do Which values are What are you ready when the going gets important to you? to let go of? tough? How can you live a How are you going How can you life according to to do this? remind yourself your values? when it’s easy to forget? An excerpt from a compassionate letter “I feel so tragically sad that you have been through so much on your own and endured so many horrific experiences through no fault of your own. All alone, there was no-one you could turn to for comfort, love, and support. Your pattern was set; you endured growing up in an environment which was frightening and scary. The adults around you controlled you and the dark, dirty secrets you felt were wrong were part of your normality. Sadly, you were used and abused for years, continually raped and put down leaving you feeling disgusting, bad, and like you had no right to live… …It is truly important you really understand and accept that none of this was your fault. These people abused you and your trust and tragically robbed you of a carefree, happy, fulfilling childhood where you were safe to grow and develop into the beautiful person you have become today. There is no shame that should be yours. The shame belongs firmly with those who have abused you. You are no longer alone. Stand tall, be kind to yourself in actions and in words. Talk to yourself gently in a soothing voice. Recognize and accept your vulnerabilities and be kind to yourself in those moments. I love you and always will ‘Emma’ ” Thank you. Any questions? Address Maple House, The Slade, Horspath Driftway, Oxford, OX3 7JH Telephone 01865 902634 Email [email protected] Substance Misuse, Addiction and Recovery An Introduction Dr Jenny Svanberg Consultant Clinical Psychologist Some questions to consider What is a drug/substance of use? What is the difference between drug use and addiction? Is there a difference between drug/alcohol addictions and behavioural addictions like gambling? Why do only some people get addicted and not others? Is addiction a disease? Is it a choice? Case example June is 19. She’s just started at university, studying psychology. She, like her friends, experimented a bit with alcohol and cannabis as a teenager, but never had a problem with it. She was anxious about going to university and worried about making friends. However, going out and drinking helped her to feel more confident and less self-conscious. She made friends, and they would all go out together. She started to drink before going out with her friends, and would drink more and faster than the others she was with. A few times, she couldn’t remember what happened, and one friend told her she was worried about her drinking. Case example This made June feel ashamed, and she pretended that everything was fine. Her worry about what people thought made her feel panicky, so she continued to drink to manage this. Every morning, June would feel acutely anxious. Her heart would be pounding, and she would feel sick and shaky. She thought that her anxiety was getting worse, so she sometimes had a drink earlier in the day. She was now drinking every day. She had a part time job, but most of her money was going on alcohol. She wasn’t eating enough, so was losing weight. Case example Towards the end of her 2nd year, she realised that lots of her friends had cut down their drinking to focus on work, and she didn’t know how to. She tried to cut down a few times, but always just went back to it. She had started to become defensive and irritable with her friends, and some of them no longer contacted her when they were going out. She felt stuck, and hopeless, and the anxiety had never gone away. What is a substance use disorder? Use puts person or others at risk Use causes relationship problems or conflicts Within a 12 month Use gets in the way of responsibilities at period: home, school or work 2-3 = mild disorder Stopping use leads to withdrawal 4-5 = moderate Tolerance develops disorder Use larger amounts for longer 6+ = severe disorder Increasing unsuccessful attempts to control or stop use Increasing amounts of time spent using (DSM-V) Health or psychological problems resulting from use Neglect of previously enjoyed activities in favour of use Cravings Why use? It’s not about the object of addiction, but the relationship to it. Why would someone continue using when they don’t enjoy it any more? Why does June drink when she knows it’s not good for her? Consider the function of the drug or alcohol use For June, alcohol provides confidence, and a way of coping with anxiety and low self-esteem. Other functions of use might include: A social identity and group to belong to A way of reinforcing social connection A way of reducing emotional pain, and blocking out the past (in the short term) A way to avoid responsibility, relationships, activities A way of punishing the self, or someone else. To reduce or avoid physical withdrawal How do we form habits? Cue Craving Reward Activity How do we form habits? Cue Craving Reward Routine Behavioural principles of learning Operant Conditioning (Skinner, 1948) Negative or positive reinforcement makes a behaviour more likely to be repeated Punishment lead to a behaviour being extinguished or reduced Intermitten/unpredictable reinforcement leads to greater behavioural change, which persists for longer Links to ‘associative learning’ in the brain: the more we repeat a complex behavior, the stronger that brain pathway becomes A balance between brain systems Impulsive habit- forming (automatic, rigid) AMYGDALA/ STRIATUM Reflective decision Internal states, making, control of sense of impulses, longer ‘imbalance’, term planning subjective urge or PREFRONTAL craving CORTEX INSULA Noel et al, (2013) How does someone become addicted? They learn that a behaviour brings pleasure, or reduces pain. This stimulates reward centres in the brain, and feels good! They begin to associate other aspects of the behaviour with this wanted outcome, and things that remind them of the behaviour may trigger the ‘wanting’. Over time, repeated use may lead to the behaviour becoming compulsive, as the reward centres in the brain are harnessed towards the pursuit of the desired object. Their attention and memory become focussed on the behaviour and its outcome. They may no longer like the behaviour, but they still want it. So can addiction be a choice? Is addiction a choice? Drug or alcohol use is initially chosen. However, the compulsive nature of addictive behaviour means that choosing not to use becomes more difficult over time. Behaviour becomes increasingly more automatic over time, and the reward system harnesses more cues into the network, so a greater number of triggers tip the person into the reinforced addictive behavior patterns. Is addiction a disease? There is an ongoing controversy over whether addiction is a disease or not. Arguably, the disease model skews the understanding of addiction to the most severe end of the spectrum, and emphasizes biological aspects over psychological and social. It is also unique as a disease, in that some of its consequences are criminalized, and those with addiction-related difficulties are punished. However, for some people who have addiction- related problems, it can be helpful to see addiction as a disease. It is a way to find meaning and identity. For others, it can be an unwanted label. Biological factors: Genetic and epigenetic influences Drug factors Brain changes Social factors: Psychological factors: Earlier age of first use Early life adversity/exposure to Family/community/Culture trauma Substance availability Personality factors Peer group Poor mental or emotional Socioeconomic factors health Impact of stigma An example of the social context influencing ‘drug use’: Rat Park The original studies supporting a biological view of addiction as a brain disease came from rat studies in the lab The rats were housed in cages with no stimuli other than a water bottle laced with morphine. The rats used the morphine until they became addicted, which was interpreted as supporting the views of drugs as highly addictive Prof Bruce Alexander and his team in the 70s placed rats in enriched environments, ”Rat Parks” Rats in these environments consumed less morphine, though sample sizes were small, and replications have been mixed. The results have been used to highlight the importance of social and physical environment in encouraging or reducing addictive behavior. Addiction and co-occurring difficulties: June Alcohol Use Anxiety Low Self-Esteem ?Depression Addiction and Recovery Recovery is the norm, not the exception Recovery from addiction is defined as: “ a process through which an individual is enabled to move on from their problem drug use, towards a drug-free life as an active and contributing member of society” (the Road to Recovery, 2008) “Voluntary, sustained control over substance use which maximises health, wellbeing and participation in the rights, roles and responsibilities of society” (UKDPC, 2008) Stigma about drug use and addiction can create a significant barrier to recovery Types of treatment and intervention ) Community approaches Couple and family approaches Individual approaches: medical / psychological How can psychological interventions help? Psychological interventions for substance use disorders aim to support recovery by helping people to: Change their behaviour Address co-occurring mental health difficulties Psychological Principles of Effective Behavioural Interventions Developing Reinforcement Motivational Behavioural of Alternative Enhancement Impulse Behaviour Control Carroll & Rounsaville

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