We don’t have to be homogeneous – we just have to hear each other
If, as Nye Bevan put it, we have been dreamers, sufferers, then builders, then South Wales was a fitting setting to consider the future of clinical psychologists in healthcare as we know it. So began this year’s British Psychological Society Division of Clinical Psychology conference, in a rainy corner of Cardiff in mid-January, with a programme as diverse as the profession itself, including prominent representation from the health faculty, pre-qual group, experts by experience and those in independent practice, along with the return of the Clinical Psychology Fringe.
The event opened with Susan McDaniel, former American Psychological Association President, arguing that psychologists have a unique ability to understand and address many global issues. For instance, on political polarisation, social and systemic principles posit that the prosperous values of globalism are not shared by those struggling to survive, and existential pressures incite nationalism and authoritarianism as a response to perceived threat, but that reconciliation is possible. McDaniel continued by citing examples of psychologists making a positive impact in several areas, from healthcare policy to preventing radicalisation, ultimately challenging ourselves to ask, ‘am I of service in the best possible way?’
McDaniel’s call for us to consider what clinical psychologists have to offer the world was especially timely: in the current climate of austerity and threatened privatisation, it is imperative to demonstrate the need for Clinical Psychologists in the workforce. To this end, delegates were asked to participate in creating a consensus statement over which essential roles of clinical psychologists should be prioritised. Delegates voted for: Working with the government and policy makers; Community Psychology; Working in Primary Care and GP surgeries; Training and supervision of multidisciplinary teams; and Public health and prevention.
Funding for clinical training also remains under threat, as no decision on salary has been reached beyond the 2018 intake. This announcement, and the lack of clarity from the DCP Exec on alternative funding models, is frustrating for those in the application process, wondering if they will be priced out of the profession if unsuccessful this year.
Upholding the community psychology theme, Jacqui Dyer, Labour Councillor and expert by experience, explored the mental health challenges and needs of BAME communities through the prism of epistemic injustice. Jacqui stressed the need to collectively push for more collaborative, accessible, culturally-aware services, led by a more diverse workforce – a vision of equal opportunity that is unlikely to be fulfilled if the current trainee funding model is cut.
As Clinical Psychologists must consider their impact on the healthcare system they operate in, the presence of a critical perspective on teaching and practice was equally controversial and crucial. John Cromby (University of Leicester) conveyed the compromising nature of psychology’s false dualisms, including neglect of social contexts, inviting reflection on how trainee’s anxieties are entangled with their social and material circumstances. In clinical work, Cromby advocated critical reflection on service priorities, and consideration of whether the proliferation of branded therapies equates to Market Stalinism. Provocative figure Craig Newnes took a humorously critical take on diagnosis, psychometrics and proximal influences on therapy, whilst classroom dynamics were overturned whilst exploring lessons learned by teachers of critical psychology from students.
Also divisive was the launch of the Power Threat Meaning Framework, an alternative to diagnostic classification, and discourse on upholding psychological reflection and formulation in diagnostically-based systems, both led by Lucy Johnstone. Whilst the details of the framework and the idea of abandoning diagnosis received a mixed reception, sparking discord both in the room and on Twitter, the need to consider individual service users’ preferences was rightly emphasised.
To close, Susie Orbach reiterated that psychology is firmly part of the social justice agenda, affirming that therapeutic skills have a place in policy making. Orbach argued that policymakers often overestimate rationality and misconstrue motivation, inadvertently blaming those they aim to help and triggering a spiral of exclusion. Conversely, psychologically-informed policies acknowledging resistance, transference and disavowed feelings have the potential to enhance and nourish people, in contrast to the passivity of nudge economics.
Despite the varied programme, the message was clear: Clinical Psychology faces a time of considerable change and uncertainty. Being bold will require challenging systems and causing constructive disruption, but as Susie concluded: we don’t have to be homogeneous – we just have to hear each other.
Containment without Disempowerment
Mental health services often face a dilemma between providing containment for people with relational or personality difficulties, and inadvertently repeating patterns of abuse and neglect. Constructing services and interventions for those at risk of becoming disempowered by services, or excluded altogether, remains essential.
Stuart Mitchell (Northumberland, Tyne & Wear Foundation Trust), gave an overview of the implementation of a specialist Personality Disorder pathway. Based on Livesley’s framework for Personality Disorder management, psychological input is utilised early in the pathway, from initial stabilisation to implementing change, based on the individual’s priorities. The service has received no complaints since the project’s inception, and has allowed the trust to make significant financial savings.
A relational perspective on the use of Community Treatment Orders (CTOs) for this clientele was then discussed by Andrew Hider, from Ludlow Health Care. CTOs have been found not to affect admission rates, and therefore are not achieving their intended purpose, but continue to divide opinion. Some service users see CTOs as a safety net; others find it coercive. An attachment perspective posits that CTOs symbolise the nature of the individual’s care, and are more helpful in some stages of treatment than others. Whilst CTOs can provide containment, representing a successful treatment period, or external encouragement, they may invoke feelings of incompetence or powerlessness when the service user is implementing change independently, and therefore may hinder recovery in the long run.
For people with complex and longstanding difficulties, accessing psychological therapy can be particularly difficult. Isabel Clarke (Hampshire IAPT), presented a new model based on the Comprehend, Cope and Connect formulation, for those falling between primary and secondary care, or present as ‘stuck.’ Individuals are offered four individual sessions for formulation, identification of vicious circles and goal-setting, and then allocated to a twelve-session group, focused on managing relationships with themselves and others in the present and acquiring skills for the future. Preliminary outcomes showed a reduction in Depression symptoms, and anecdotal reports of a positive impact.
Meanwhile, a service in Sheffield took a different approach to setting up a psychoeducation group. Alex Satchwell and Sue Sibbald explained that, whilst not a replacement for therapy, the group helped its members to understand emotional sensitivity and manage distress using DBT skills. Participants reported that feeling understood was very helpful, and a positive impact was reflected in data showing confidence in using skills in a crisis and hope for recovery.
Lastly, Kate Oldfield, also from Sheffield Health & Social Care, discussed a project implementing shared psychologically-informed care in acute settings, also using the Comprehend, Cope and Connect model. The safety of the hospital environment can make it difficult for the service user to create an internal sense of safety, so a consistent approach to care and a compassionate alliance may enable individuals to better understand a crisis and develop shared responsibility between the individual and services. This approach has prevented disengagement by identifying and avoiding unhelpful team responses.
Findings from an initiative to improve service user engagement was awarded the conference’s poster prize. Chat Café, set up as an informal space, offers a choice of activities, from psychoeducation to coping skills, in a relaxed and sociable setting. Susana Lara and Grace Johnstone, supervised by Doreen Hoerold, presented feedback data and case studies suggesting that engagement was more likely with chat café than conventional psychology groups, which can feel intimidating.
Prizes were also awarded to Robert Searle, for his poster on constructions of masculinity amongst men experiencing psychosis, and Sasha Priddy, for an exploration of dual diagnosis.
Understanding Unusual Experiences
Following the release of the BPS public information guide, Understanding Psychosis and Schizophrenia, edited by Anne Cooke, disseminating research on understanding and working with Psychosis was firmly on the agenda. Cooke discussed the mixed reception of the publication, which was developed in collaboration with service users and motivated by misinformed media coverage and pessimistic prognosis. The guide has been revised to improve representation of BAME communities, and it is hoped that this version could form the basis of a training package in the future.
Edel McGlanaghy, Trainee Clinical Psychologist at Edinburgh University, outlined her project conducting a network meta-analysis of psychological treatments for psychosis. On completion, Edel aims to produce a grid comparing the efficacy of each type of intervention, to inform individual choice. The results also indicate future research needs, such as additional trials of third-wave approaches.
One such approach, Compassion-focussed therapy, has been shown to be beneficial to those in the acute stage of psychotic illness. William Fewtrell described a novel intervention in which brief, thrice-weekly individual sessions were offered to clients whilst in hospital, starting within 24 hours of admission. The empathic style of the sessions was intended to establish rapport through a shared understanding of each individual’s psychotic experiences, and this was reflected in an improvement on measures of therapeutic alliance and a marked increase in consent to further sessions, from less than 40 per cent to over 80 per cent.
Two Psychologists from Northumberland, Tyne & Wear Foundation Trust turned the emphasis to understanding and working with visual hallucinations. Charlotte Aynsworth explored the idea that, as with auditory hallucinations, visual hallucinations may be due to a tendency to misattribute internal experiences as external. When presented with a mix of pictures and word stimuli, participants with visual hallucinations were more likely to misremember the words as being presented as pictures, likely due to a greater tendency to remember the words by imagining them as pictures. The findings can be used to further research in multimodal hallucinations, as people who experience visual hallucinations are also likely to hear voices, and to help service users to rationalise their experiences, as distress in response to hallucinations has been shown to increase them. Christina Thomson then discussed outcomes from a CBT intervention for visual hallucinations. Improvements were found in levels of distress, and belief in the meaning given to these experiences, with a change in their frequency for some.
Finally, Simon Riches, from King’s College London, discussed improving understanding and empathy for voice hearers through an immersive art exhibition. Altered States of Consciousness, which opened to the public, simulated voice hearing and paranoia using audio and visual installations. Each visitor’s audio guide conveyed live feedback from an actor, who could see the visitor and therefore tailor the speech to the visitor’s location and actions for a more realistic experience. Data collected before and after exhibition showed an increase in understanding and compassion towards voice-hearers, with participants also reporting finding the voices surprisingly compelling.
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