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Wardipedia – 68. Talking therapies

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Beyond CBT….

Introduction

Talking therapies, psychologically minded staff, mentalising… all as essential as medication on inpatient wards. (And usually without the nasty side-effects often inflicted by medication.) A patient may be  continuing with their pre-hospital therapy or experiencing psychotherapeutic  relief, challenges and changes for the first time. Medication does wonders in knocking some symptoms on the head but can’t begin to address the underlying emotional issues which cause or compound extreme mental distress. Casual conversations with staff (and other patients) can sometimes produce life-changing insights, as can 1:1 sessions with key-workers and CPA co-ordinators or even consultants. But profound and sustainable emotional changes can only come about through psychotherapy.

There are now some very ‘niche’ talking therapies (eg Validation Therapy for people with dementia) and we’re witnessing a shift from CBT (cognitive behavioural therapy) being the only show in town. Recent developments with IAPT (the large-scale Improving Access to Psychological Therapies programme) reflect and indeed have contributed to the recognition that while CBT is undoubtedly wonderful for the individuals it suits, more specialist treatments are needed, in particular for people with more complex symptoms and experiences. The thing we’re really excited about is that IAPT is extending into inpatient care.

There’s a heartening diversity of psychotherapeutic approaches and options available for inpatients such as

  • Hearing voices group
  • Anxiety, stress, and anger management groups.
  • Moving On group (including discharge planning).
  • Nursing staff trained in psychotherapy and ‘alternative’ therapies eg aromatherapy.
  • Chaplain runs regular recovery groups for patients.
  • IAPT (improving access to Psychological Services).  Service users are advised about what may be available to them following their discharge from hospital.
  • Clinical psychologist runs drop-in consultations for staff.
  • self-harm project run by a specialist nurse, including a camouflage clinic for those who want this resource as well as support group, staff and training.
  • Patients can access online therapy
  • BME groups providing counselling in mother tongue languages. And a huge, beautiful library that’s well used by patients as well as staff, including patients from the on-site mental health units.

Psychotherapy for inpatients can be unhelpfully squashed down into being about ‘therapy for acute patients’. But of course this is only one group of hospital users, and just as there is huge variety in people’s illnesses, chronicity and life situations, so a variety of therapeutic techniques are used in hospital. More in-depth, potentially unsettling, longer-term therapy is possible on a rehab ward, for example, while solution focused therapy can be very helpful with many patients on acute admission wards. Here it’s likely to be less about coherent narratives, insights etc and more about the other valuable aspects of therapy – therapeutic alliance, feeling heard, supported and respected even if not fully understood etc.

Similarly, more intense psychotherapy might be appropriate towards the end of a patient’s stay, especially if it’s possible to continue this when the patient is back home. (Ideally with the same therapist, eg a CPN.)

According to The Centre for Mental Health, the full-time clinical psychologist to inpatient ratio should be 1:20 in hospital. Other advisors would add a full-time assistant psychologist to this in the ratio 1:40. Our view is vaguer but passionately held: psychological therapy should be available to every patient who wants it and a clinical psychologist or similar specialist should also provide staff training, support and supervision.

We’re very taken by the sound of some of the less mainstream therapies such as Sand Therapy and Pre-therapy, outlined below. Pre-therapy is particularly compelling as it’s essential to try creative, non-verbal styles of healing contact with people who are non-verbal or in a real old cognitive pickle. It’s close in concept (and perhaps practice) to Intensive Interaction. To save you having to click over to Idea, here’s what it says about Intensive Interaction:

Intensive interaction is about using everything that your ‘communication partner’ provides, and because it’s designed for people who use little or no speech, body language and behaviour are carefully considered. A really valuable concept from intensive interaction is about taking the lead from the other person, building on the communication methods, style, pace etc they use, enjoy and can comfortably manage.

For us, the outstanding model for integrating a psychotherapeutic approach into daily life is the therapeutic community. This is how the Association of Therapeutic Communities describes TCs:

Therapeutic Communities (TCs) are ‘psychologically informed planned environments’ – they are places where the social relationships, structure of the day and different activities together are all deliberately designed to help people’s health and well-being. In some TCs, people with various longstanding emotional problems spend time and engage in therapy together in an organised and structured way, without drugs or self-damaging behaviour, so that a new life in outside society is made possible. There are others living in TCs who cannot live normally in society (for reasons such as severe learning disability or persistent psychosis) and engage in an interdependent form of group living which helps them to have a more fulfilling life and achieve their maximum social potential.  The workings of the therapeutic communities themselves are the main method, and through these social and group processes, change and growth are promoted.

Therapeutic communities are the most full-on, systematic manifestation of a ‘therapeutic milieu’.  But the principles and skills are also used continuously by ward staff, including

  • Distribution of power
  • Open communication
  • Structured interactions
  • Work- related activities.
  • Community and family involvement in the treatment process
  • Adaptation of the environment to meet developmental needs.
  • To promote a fundamental respect for individuals (both clients and staff).
  • To use opportunities for communication between client and staff for maximum therapeutic benefit.
  • To encourage clients to act at a level equal to their ability and to enhance their self esteem( autonomy is reinforced)
  • To promote socialization.
  • To provide opportunities for clients to be part of unit management.
  • Individuals are held responsible for own actions.
  • Peer pressure is utilized to reinforce rules and regulations.
  • Team approach is used.

Ward examples

Therapy Groups and Sessions

  • Talking therapies are inspired by Irving Yallom’s style of inpatient psychodynamic therapy – very adaptive, here and now, focusing on altruism and patients helping each other. It was interesting to learn that they have an Understanding Psychosis group, whose name reflects that it covers more than hearing voices.
  • Hearing voices, music therapy, drama therapy.
  • Recovery groups:-  Enabling people to share personal experiences of recovering from mental illness and to hear how others have coped.
  • Weekly 45 minute ‘talking therapy’ group.
  • Food and mood group.
  • Mental health discussion group.
  • Anxiety, stress, and anger management groups.
  • Moving On group (including discharge planning).
  • Self-help group with local support group.
  • All patients have an individual therapy programme which is negotiated on a needs lead basis with the patient.
  • All patients have individual therapeutic timetables which incorporate at least 25 hours per week of structured therapeutic activity.
  • All patients are offered at least one hour per week of individual or group psychotherapy.

Staff Training

  • Lots of staff have gone on enhanced skills training, including CBT. Patients benefit considerably from the ward being able to access on-site specialist services including those for anxiety and for eating disorders.
  • Staff supervision includes a fortnightly staff support group interestingly, facilitated by the chaplaincy, in secular mode.
  • Nursing staff trained in psychotherapy and ‘alternative’ therapies eg aromatherapy.
  • All qualified staff and some support staff have at least one therapy course either Psychosocial Interventions (P.S.I.), Cognitive Behavioural Therapy (C.B.T.), or Solution Focused Therapy.
  • Most unqualified staff have training in P.S.I .
  • Staff have received psychology training sessions, among others, in basic cognitive behavioural therapy and working with self-harming behaviours and post-traumatic stress.
  • One member of staff is trained in Neuro-Linguistic Programming.
  • Nursing staff trained in psychotherapy and ‘alternative’ therapies eg aromatherapy.

Input from the Wider MDT and Services

  • A visiting psychologist runs a discussion group twice a week.
  • Clinical psychologist runs drop-in consultations for staff.
  • Chaplaincy staff are trained in counselling.
  • Chaplain runs regular recovery groups for patients.
  • IAPT (improving access to Psychological Services).  Service users are advised about what may be available to them following their discharge from hospital.
  • The ward’s Therapeutic Liaison Worker is trained in counselling and group therapy.
  • Self-help group with local support organisation .
  • Clinical psychologist runs drop-in consultations for staff.
  • A scheme has been developed where volunteers work within the Psychology Department and the Occupational Therapy Department on a sectional basis.

Self-harm

  • The hospital has a very interesting, unusual self-harm project run by a specialist nurse, including (brilliantly) a camouflage clinic for those who want this resource as well as support group, staff and training.
  • The importance of doctors supporting a more liberal ‘safer self-harming’ approach in order for the ward to be able to implement this. A dynamic local multi-disciplinary group, has produced resources to support this work and each ward has a self-harm resource file with lots of information including in different languages. There’s a similar resource for sexual abuse.

Resources

  • Patients can access online therapy such as the web-based CBT for depression programme, Living Life to the Full.
  • Personal recovery files which include sections for patients to fill in – eg by journaling.
  • 5 core central patient library areas have been set up in adult and older peoples services that will have self help resources for service user, carer and staff reference.  These hold self-help booklets, 19 relevant NICE guidelines for patients and additional self help text books.
  • Daily diaries and personal recovery packs; self-help books and tapes /dvds.
  • The hospital has a vibrant therapies unit. A dance and movement session was going on in the gym when we visited, led by a specialist in this important combination of art and exercise. The artwork done achieves numerous objectives, ranging from an opportunity for a non-intrusive, relaxed OT assessment to producing truly high quality (luxury shop standard) products which are used on wards or can be taken to patients’ homes or given to their families.
  • A de-escalation room with resources for self-soothing including ‘care bags’ which appeal to the senses of sight, touch and smell. The room includes a rocker, light projection and body-sized bean bags.
  • The hospital has a stunning advice and information centre. The centre includes a suite of meeting rooms used on a totally inspired ‘time-share’ basis by local voluntary organisations, for example BME groups providing counselling in mother tongue languages. And a huge, beautiful library that’s well used by patients as well as staff, including patients from the on-site mental health units.

Types of Therapies Offered

  • Talking therapies offered:
    • Cognitive behavioural therapy
    • Dialectical behavioural therapy
    • Cognitive Analytical Therapy
    • Mentalisation Based Treatment
    • Brief solutions therapy
    • Trauma focused counselling.
    • Family therapy
    • Emotional Skills and mindfulness: Enables people to find ways of managing intense feelings in a safe and supportive environment.
    • Art therapy
    • Music therapy
    • Drama therapy
    • Wellness Action Recovery Planning
    • Self help resources

The word from the ward

“We are fortunate to have access to a clinical psychologist who help us run therapy groups and individual sessions. ‘Recovery groups’, ‘independent living’ and ‘anxiety reduction and coping sessions’ can be extremely beneficial to inpatients. They can provide a safe environment for issues to be discussed, problems faced during the week to be faced and for patients to learn and gain skills they can use in their recovery. At times however these professionals aren’t available, there is no need to be disheartened or deterred from putting on an informal therapeutic session or activity. The rewards for patients are boredom levels are reduced, new strategies and invaluable skills in stress reduction and symptom coping skills can be developed and the most important they can have fun!” (Healthcare Support Worker)

 

Patient examples

  • On my ward we do group therapy and have access to individual therapy. It is interesting how helping others talk through their problems opens your eyes to your own.
  • I used to just talk about my goals. Now I give them a go. Confidence and encouragement were the critical elements in changing that.
  • Therapy has taught me so much. There isn’t a day that goes by where it doesn’t come in handy.
  • I found the therapy group really helpful. It made me realise I was not the only one with the same thoughts and problems.
  • You’ve got to remember your symptoms and your illness aren’t who you are. You’ve got to find who you really are under that.
  • Many of us would avoid talking about ourselves and would just talk about others. The staff were quite hot on this and helped us feel ok as individuals.
  • I keep in touch with my community therapist by email so that I feel supported when I leave.
  • Therapy was a precious and safe space for me. It was where I really got to know myself.
  • The staff understood that I used to struggle immediately after a therapy session and put support in appropriately for that time.
  • I still regard my therapist as a VIP in my life even though I no longer need to see her.
  • Going to a problem solving group on the ward really helped me.
  • Even if you feel really stuck and hopeless seeing others progress in the groups is encouraging and you think ‘Yeah, I might be able to get there too’.
  • I was really angry when I didn’t find the first therapy I tried helpful. But there are so many more and I finally found one that I got on with and worked really well.

A little note from Marion

In my experience as an inpatient, there are few people on acute admission wards who wouldn’t benefit from (nor be willing to attend) therapy, and particularly as the time to return home gets closer. The vital factor is that the therapy is suitably low-key and the therapist warm, personable, sensitive and very flexible.I’ve been incredibly fortunate that I’ve been able to continue to have my weekly therapy sessions with my psychiatrist when I’m in hospital. No need to drive to the appointment like usual, I can just shuffle the 100 yards n my slippers (see featured image above). Result!

Snippets

Many of the snippets below are taken from the Star Wards newsletter which focused on inpatient psychotherapy.

Psychotherapy for Acute In-patients

Unfortunately, there is relatively little known about the benefits, or otherwise, of psychotherapy for acute in-patients. It’s tempting, almost common sense, to think it can only be a good thing. But there are complex issues about patients’ ability to engage in what can be painful or challenging therapy when they are seriously ill, as well as concerns about potential discontinuity of treatment when they leave hospital.

A small scale, very radical American initiative is described by Deikman and Whitake in Humanizing a Psychiatric Ward – changing from drugs to psychotherapy. These two doctors transformed a ward from being almost entirely medication oriented to one operating instead largely on the basis of group and individual psychotherapy. There were considerable gains made by patients during this 10 month ‘experiment’, but there were all sorts of problems with the process which make it impossible to draw any conclusions other than it was a pretty extraordinary thing to do.

If you want to get down to some serious talking and soul-searching, therapeutic communities are the place to be. They offer a tantalising model for embracing psychotherapy as a core treatment tool. Several successful therapeutic communities are discussed in the book (from the No Surprises Here school of book titling) Therapeutic Communities. There is so much to be learnt from this intensive, people-centred approach, even in the necessarily diluted and short-term form it would take on an acute ward.

A more modest pilot project is included in From Toxic Institutions to Therapeutic Environments. Manchester’s Edale in-patient unit employed assistant psychologists whose role included “carrying out simple [therapeutic] interventions under supervision.” Interestingly, their role also covered working with the unit’s occupational therapist to develop in-patient activities, training staff and supporting ward community meetings. The project seems to have been popular and to have created reasonable benefits for patients, but it’s unclear whether, like so many successful pilot projects, it was discontinued.

Perhaps the strongest advocate for psychotherapy on acute wards is Jeremy Holmes, who, like the much admired Anthony Bateman, somehow manages to combine being a consultant psychiatrist and psychotherapist and university lecturer. In an article on Creating a psychotherapeutic culture in acute psychiatric wards, Holmes laments the fact that the last few decades has seen the paradoxical demise of “ward groups and the importance of patients playing an active part in decision-making” at the same time as community care was being introduced. (And thank goodness for community care and the end of the old ‘asylums’.) Holmes notes that “Hard evidence that psychological therapies can play a significant role in in-patient care is far from robust, perhaps because the attention of the research community has been focused elsewhere. Nevertheless, the research literature does provide some grounds for thinking that psychological approaches might play an important role in improving quality of care in the in-patient setting.”

But until the gap in research on psychotherapy on acute wards is filled, it’s a relief to find a practitioner and academic who acknowledges that patients are likely to benefit from talking therapies.

 


 

Professor Jeremy Holmes describes the use of talking therapies on inpatient units
From Star Wards newsletter #57
A crucial ingredient in mental health is the capacity for self-reflection, or mentalising as it is now called – which I define as the ability to see oneself from the outside and others from the inside. ‘Talking therapies’ have an essential place in fostering mentalising and are needed in the in-patient unit at three levels.

First, the stresses and challenges of working on in-patient wards means that staff members need a safe space where they can reflect on their own feelings and actions, and come to understand them both in terms of their own lives, and those of their clients. A weekly or better still daily staff group, facilitated by a skilled group therapist, where hierarchies can be levelled and the team reflect on itself, is in my view an essential element in any well-functioning in-patient psychiatric ward team. The leadership and endorsement of this must come from the top. Resistance must be seen as a normal and expectable response, carried perhaps by some recalcitrant members who are acting out the difficulty of facing one’s feelings for the whole group.

Building on that, daily or twice weekly community meetings where the whole unit – patients and staff alike – come together to discuss the practical and emotional aspects of living together is also highly desirable. Such large groups can be stressful and at times disrupted, but have a vital holding function that helps create cohesion and compassion within the unit, and is a place where the inevitable tensions of group living can be explored.

Thirdly, many individual patients need regular, preferably daily, one-to-one sessions with staff members, who themselves have access to a supervision session where their interactions with the patient can be discussed in an open and non-judgmental way. These sessions will vary is style and content. Many will provide an opportunity for the patient to review their life-history and the part played in it by their illness. Support and validation are essential. Some may benefit from Cognitive Behavioural (CBT) approaches, e.g. in dealing with psychotic phenomena. Others may want to look in depth at the ways in which factors in their life of which they are unaware may have played a part in their breakdown. Thus training in Rogerian Counselling, CBT, and psychodynamic thinking will all be important in the skill-mix of a fit-for-purpose in-patient psychiatric unit.

Prof Jeremy Holmes MD FRCPsych

Consultant Psychiatrist (retired), Devon partnership Trust
Visiting Professor Psychological Therapies, University of Exeter

 

Tea and Therapy: A Dialogue with Karen
From Star Wards newsletter #57
The patient so compellingly described in Patrick’s piece has given her agreement for this to be shared and identifying details have been changed

The first time I met Karen, she asked me if I wanted a cup of tea – a nurse told me later it was the first time she had spoken in eighteen months.  I was new to the ward and I felt a little ill at ease with her silence initially, but she reassured me:
“It’s okay, you don’t have to say anything y’know.”
I knitted my eyebrows in confusion.
“Let’s just sit here for a while; I think I could deal with that.”
“Of course.”
She nodded and returned to staring out of the window and sipping her tea.
It was during Karen’s first session that I really began to understand what it was merely to listen and observe – and sit with someone.  The ward was quite chaotic and I could hear snippets of conversation in the day-room; chairs scraping on the floor; the ward clerk walking past in her high heels. At the end of the session Karen walked towards the door, paused and asked without turning around, “Could we talk about the voices next week?”
“We can talk about anything.”

The week after, Karen slowly began to talk more and more.  She didn’t talk about the voices to start with; there was an unspoken agreement that we would get to the voices.  Instead we talked about: the weather; the news; how she liked the view of the cherry blossoms from her bedroom window at home; her favourite pet cat Ozymandius – Ozzy for short; how she trained as a teacher before she got ill; my garish ties – anything and everything.

Karen liked to make top 10 lists: top 10 favourite sweets from the Eighties, top 10 favourite singles; top 10 favourite films of all time.  Here there was common ground and a shared experience through dialogue and reflection – and it was fun.

One day about three months later, Karen finally felt comfortable enough to tell me about the voices and the reason she was unable to speak for so long. She explained that she had so many voices that she couldn’t hear herself think or speak and that it had been easier to stay silent.  Sitting with someone – someone simply being with her had allowed her to find her voice again.

Over the following weeks we started talking to the voices: asking them why they bothered Karen.  One by one they agreed not to give her such a hard time, or to leave her alone completely.  Outside the sessions she began chatting with the nurses and attending OT.  Sometimes Karen asked if the nurses could sit-in on the sessions so that they could learn to help with the voices.

Karen was eventually discharged from hospital and went back to teaching.  She is now a successful Lecturer and motivational speaker and uses her inpatient experience to help staff and patients.  Karen’s story is not unique though.   In a sense it’s everyone’s story: we all need to be understood.  Engaging in dialogue is often borne out of a shared silence.   Sharing an experience with someone, even if it is silence, creates the opportunity for dialogue, and dialogue can often lead to understanding. In the words of the Swiss physician Paul Tournier:
‘No one can develop freely in this world and find a full life without feeling understood by at least one person.’

Patrick Doyle is a Clinical Nurse Specialist and Psychotherapist working within a medium secure hospital.  He is the founder of Person First Solutions, who provide mental health training, consultancy and clinical services for the NHS, private and voluntary sectors.

 


 

Individual and Group Therapy
Most forms of psychotherapy benefit from a one-to-one relationship between therapist and client, but group therapy also has distinct benefits and lends itself well to the community nature of a ward setting. In group therapy, groups find solutions together, guided by a facilitator. In a group setting, members can learn about their assets/deficits through interaction with their peers and staff; they can also experiment with newly learned behaviours in the protected environment of the group before taking them out into the world.

Historically, at the turn of the 20th Century, a Boston physician first held group sessions to educate poor tuberculosis patients for whom a sanatorium was not an option on how to fight the disease through strict hygiene regimens at home. Freud later recognized the dynamics of group relationships and the role of the charismatic leader. Psychoanalytic and interpersonal theory was integrated in group therapy concepts. In the 1960s sensitivity training (T groups) and personal growth groups began, followed by transactional analysis, gestalt theory, and many other variations. Important innovations were group approaches in the workplace, the study of group morale, and management of large groups through the role of the ‘command psychiatrist’. Types of therapeutic groups are self-help, medication, encounter, interpersonal therapy, and psychodrama.

Various models of inpatient group psychotherapy share several features, especially establishing specific goals according to the particular needs of the patients.

Skills development models include: –

  • The educative model: patients discuss the problems which led directly to their hospitalization and find ways of coping.
  • The problem solving model helps patients to acquire interpersonal problem solving skills. The steps are clarifying the problem, generating and evaluating alternatives, role-playing and reporting back to the group.
  • The social skills model is behaviourally oriented and fosters the acquisition of various interpersonal skills by dividing each skill into several behavioural components.
  • The interpersonal model emphasizes the social isolation of inpatients and their difficulties in interacting with others, focusing on current problems. In each session, members consider one interpersonal problem that can be addressed within one session.

Some popular and some rather obscure but fabulous psychotherapies

Psychosocial interventions (PSI)
PSI uses cognitive behaviour therapy techniques among others, as well as medication. Episodes of mental illness tend to be triggered through a combination of biological, environmental and sociological factors, by some life events or by stress. PSI addresses the patient’s illness in an engagement and outcome-orientated assessment, takes into consideration the views of the family, and helps with psychological as well as medication management through cognitive behaviour therapy, coping strategies, training in problem-solving, etc. PSI is one of the most common forms of therapeutic intervention on wards, with an increasing number of healthcare assistants as well as registered nurses trained in and confidently applying its techniques.

Cognitive behaviour therapy (CBT)
CBT is based on changing the patient’s negative thought and behaviour patterns. NICE recommends CBT for those diagnosed with schizophrenia, bipolar disorder, depression, eating disorder, post-traumatic stress disorder and self-harm. It is also recommended for those with personality disorder by the National Institute for Mental Health, England, although research suggests that CBT (along with other cognitively based and dynamically orientated therapies)  can be counter-productive for people with Borderline Personality Disorder.

What CBT and similar therapies do is to teach new behaviours, first in the context of the ward and later in the client’s normal life outside hospital. In hospital the priority is to help patients to make sense of their situation. Patients will probably be confused and fearful, but they need to understand how they arrived at their predicament and what they might be able to do about it. For example, one skill is to let negative thoughts and memories go on an imaginary conveyor belt and watch them being carried off. Thus the patients are encouraged to work actively towards getting well. Skilful practitioners help prevent patients
feeling somehow criticized by CBT formulations, thinking they have made themselves ill through “wrong thoughts”.

Dialectical behaviour therapy (DBT)
DBT is a special variation of CBT, developed to treat borderline personality disorder, working directly with problematic thoughts and feelings and developing skills to deal with these, both individually and in groups. It differs from CBT in looking not just at behaviours but also at their causes and consequences, and in emphasising validation, dialectics and the therapeutic relationship. DBT views borderline personality disorder as resulting from skills deficits, especially an inability to regulate emotions. It suggests that as children, people with BPD failed to learn emotional management skills because their carers produced an ‘invalidating’ environment. Skills deficits can also exist in interpersonal relationships, behavioural patterns such as self-harm, and cognitive processing such as problem-solving under emotional stress.

Dialectics in this therapy means a holistic approach, managing tensions in the patient’s outlook, and adaptability to treatment goals as they evolve. DBT also employs mindfulness, based on Zen Buddhism; validation which treats the patient’s responses empathically; dialectical strategies and other techniques. Consistent and progressive treatment is achieved by involving other professionals as well as friends and family.

Mentalisation based therapy (MBT)
MBT is a type of treatment designed for people with borderline personality disorder (BPD). Mentalisation is about understanding one’s own and other people’s thoughts and feelings, something which can be difficult for people with BPD. (See Idea #7 Mentalising and also www.mentalising.com.) Research suggests that BPD is caused by early childhood attachment issues, abuse or neglect, leading to patterns of feeling overwhelmed by intensely painful feelings which make individuals ‘automatically’ shut off their thought processes about themselves and others.

People with BPD are thought to have hyperactive attachment systems as a result of their history and/or biological make-up, which in turn leads to a reduced capacity to mentalise. MBT teaches patients in a safe and non-judgemental way to function in interpersonal relationships and to cope with extreme internal pain without externalising it through self-harm or obliterate it through drink or drugs.

At times of stress people with BPD may turn to self-harm and other powerful but obviously problematic coping mechanisms, which both divert from and prevent considering their own and others’ thought processes. MBT can help them to sharpen up their ability to mentalise and be willing to use it. For example, if a person with BPD is feeling particularly suicidal, being able to mentalise means they have to properly reflect on their thoughts and feelings, and crucially, on how their death would impact on others.

Solution-focused brief therapy (SFBT)
SBT is based on social constructionist philosophy and focuses upon what patients wish to gain from therapy instead of the problems that led them to seek help. This therapy focuses on the present and future rather than the past. The client is invited to envision what they would like their future to be, and then therapist and client together start to work towards these goals (the preferred future) in small steps. This is based on the idea that change is constant; the therapist helps the client to identify first, what they want to change and second, what they want to continue to have happen in their lives.

This theory is based on the finding that the clearer clients were about what they wanted to achieve, the more likely they were to achieve it. The therapy is very positive, using flowcharts and end-of-session compliments on what has already been achieved.

Validation Therapy
Validation therapy focuses on valuing the context of what person is saying and acknowledging the emotional component. It’s neatly put in this online article:

The idea behind validation therapy is to “validate” or accept the values, beliefs and “reality” of the person suffering from dementia. The key is to “agree” with them, but to also use conversation to get them to do something else without them realizing they are actually being redirected. So, if an 87 year old woman says that she needs a phone to call her grandmother, validation therapy says, “OK.”

The number one reason why validation therapy works well is because it is not confrontational. Never is a person belittled, yelled at, or told “no.” The biggest criticism of validation therapy is that it promotes lying. These lies weigh heavy on the consciences of caregivers and family members. For example, validation therapy says that a family member should just accept their aging parent calling them someone else’s name, not correct them.

Cognitive stimulation therapy
CST involves a series of themed, group activity sessions to help people with dementia improve their cognitive ability. A programme consists of 14 sessions of 45 minutes taking place twice a week. Impressively, the results were shown to be as beneficial to people’s thinking and their quality of life as were several dementia drugs. Activities included: physical games; sound; childhood; food; current affairs; faces/scenes; word association; being creative; categorising objects; orientation; using money; number games; word games; and team quizzes.

 

 

 

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