29 Aug 2017

Psychology on the Wards

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By Dr John Hanna, Consultant Clinical Psychologist, Highgate Mental Health Centre

All ward-based staff know the sense of achievement acquired by successfully helping a service user through a purposeful admission which aids in recovery and social inclusion. Many or most also know the frustration involved in not feeling adequately trained or qualified to meet a major area of a client’s presenting need. Most ward staff want psychologists working alongside them and want training so that they, too, can feel competent in providing psychological interventions.

The purpose of an inpatient admission to a mental health hospital will vary from individual to individual, but generally service users want an admission to be safe, to be meaningful, ideally to be brief and to facilitate optimal community reintegration. This blog sets out to promote the involvement of psychologists and the provision of psychological therapies on mental health wards, in order to achieve these valued outcomes for service users.

The current thinking about distress associated with mental health difficulties is that such distress is brought about within a biopsychosocial field; in other words, distress can be generated as a result of a biological predisposition or deficit, a psychological conflict or pattern of thinking, an aspect of social deprivation or any combination of the three. A breakdown in one area of the biopsychosocial field affects all three components of this field—if the distress is viewed to originate in biology, it will no doubt negatively impact on the psychological and social life of the individual; if problems begin in the psychological sphere, the person will suffer biologically (manifest by physical and biochemical changes) and socially; if social deprivation renders acute distress, the person will likewise struggle biologically and psychologically.

A biopsychosocial model of distress in mental health therefore requires a tripartite treatment solution: clinical interventions that, collectively, encompass the whole of the individual’s difficulties. This is not a revolutionary idea—the biopsychosocial model has held sway in mental health services for years and is widely accepted by all professional groups. It is difficult, however, to argue that the biopsychosocial needs of inpatients on mental health wards are universally met within the NHS. Psychology, in particular, has been largely absent or in very short supply on the wards for many years. But, as a result of research-based evidence, service user demand and new sources of funding, thankfully this is now changing – psychologists and psychological therapies are on the rise within inpatient settings.

Clinical psychologists – professionally chartered, applied psychologists who practice psychological therapies after many years of doctoral-level training – are widely recognised as the most capable psychological therapy practitioners in the context of severe, enduring and/or complex and risky distress. They are also the best candidates for training and supervising other mental health professions, such as nurses, psychiatrists, occupational therapists and social workers, who would ordinarily use psychological interventions in their everyday practice. Although clinical psychologists are specialists in delivering psychological therapies, especially with challenging clinical presentations, all mental health professionals are responsible for providing psychologically therapeutic interventions—from supportive counselling to solution focused problem-solving to behavioural symptom management. Without psychologists and other specialists in psychological therapy, however, both service users with challenging difficulties, and staff with psychological training and supervision needs, will struggle to meet challenges in the psychological and psychosocial treatment spheres.

The evidence base for psychological therapies, especially cognitive behavioural therapy (CBT) has grown substantially over the past few years. Specific psychological therapies for all of the mental health conditions related to hospital admission, from suicidal depression to psychosis to borderline personality difficulties, have been demonstrated as effective through numerous research trials. Each is endorsed and recommended as an essential part of standard care by the National Institute for Clinical Excellence (NICE). Not only does psychology now have a weighty evidence base, but psychological therapies are now more in demand from service users than ever before. Many people who use mental health services state a preference for talking therapies, or a combination of therapy and medication, over medication alone. Yet the NHS has a long way to go before meeting either the NICE guidance implementation targets or achieving widespread satisfaction in its psychological therapy service delivery: Every review of mental health services from service user and other organisations note a widespread dissatisfaction among service users with the quality and quantity of one-to-one therapeutic contact with staff, especially on wards in mental health hospitals, as well as with access to psychologists, who remain in short supply.

For all of these reasons, psychologists are increasingly being employed to help train and support multidisciplinary staff while taking on the most challenging psychological therapy work on inpatient wards. Some psychologists work mainly in a community team and work with their sector-based ward for a session or two a week, while others are employed within a hospital and work across wards exclusively with inpatients. Psychologists assess and formulate their clients’ difficulties and, as such, provide a different and valuable perspective on distress to both the client and the treatment team. They often provide an individual assessment and therapy service while contributing to or supporting an inpatient group programme. In therapy, psychologists help to address existential challenges related to suicidality, make sense of delusions and hallucinations, work through past trauma and loss, focus on thought patterns and lifestyle choices which can promote recovery and improve relating within social systems. Psychologists are increasingly called upon by other professional groups to support training initiatives, as all professions are now expected to provide at least basic psychological interventions as part of routine care.

It has, in the past, been argued that scarce psychological therapy resources should be reserved for outpatients, as they may be in a better position to engage in such treatment. A counter-argument to this is offered by the evidence base for psychology: NICE regularly recommends prioritising psychological therapy for those candidates whose distress is persistent and whose risk of relapse is high—this clearly includes inpatients. The counter-argument is further strengthened by the Department of Health’s National Service Framework, which similarly argues that gaps in services for people with severe, enduring and complex difficulties must be a first priority. There is no doubt that NICE recommendations need to be adapted to the time-limited nature of an acute admission, as well as to the acute distress experienced by many inpatients which will, at times, pose challenges to effective engagement. But the immediate aftermath of a breakdown necessitating admission is often the best opportunity to make sense of the precipitating factors contributing to a personal crisis. As psychologists grow increasingly confident in effectively meeting the challenges presented by the acute distress of inpatients, more within the profession are drawn to the prospect of working on wards. And the more inpatient service users find benefit from the efforts of psychologists and those they train and support, the more demand there will be for psychologically-oriented wards in mental health hospitals.

Can your local ward meet the psychological and psychosocial challenges presented by its service users during hospital admissions? If not, what can you and your Trust do about it?

 


This article is from the first version of the ‘Star Wards’ booklet, 2006

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