The Role of Clinical & Health Psychology in the Physical Health Context

Transcription

1 The Role of Clinical & Health Psychology in the Physical Health Context Jon Courthold Consultant Clinical Psychologist in Renal Services 22 nd November 2007

2 The plan The plan Part One introduction to clinical & health psychology A few words about the evidence base Some ideas about the broad scope of psychological care in renal services Part Two Core Roles / Activities Part Three Some specific Psychological Difficulties 2

3 Clinical & Health Psychology Two distinct branches of applied psychology in the UK psychology in the UK 3

4 BPS Division of Clinical Psychology (DCP) Chartered Clinical Psychologist Division of Health Psychology (DHP) Chartered Health Psychologist Emphasis on clinical context Emphasis on research, and direct clinical interventions psychological aspects of with patients psychological healthcare, health behaviours assessment & therapy Faculty of Clinical Health Psychology Division of Neuropsychology 4

5 Clinical & Health Psychology Two distinct branches of applied psychology in the UK Basic definition of psychology study of emotion, cognition and behaviour Applied in context Evidence based Bio psycho social model not medical model or psychiatric 5

6 Cochrane Review Psychosocial interventions for depression in dialysis patients Data were not available to draw conclusions about the effectiveness of psychosocial interventions in the treatment of depression in the chronic dialysis population, as we did not find any RCTs of psychosocial interventions to treat depression in dialysis patients. This review highlights the need for commencing & completing adequately powered RCTs to address the issue of psychosocial interventions for depression in dialysis patients. 6

7 Does this mean that you shouldn Does this mean that you shouldn t refer renal patients to clinical psychology? No... Evidence base for psychological interventions with depressed and distressed people generally NICE, academic literature, established practice Other issues besides depression 7

8 But there But there is is research & development work to be done... Exploring specific features of renal disease psychologically, socially and biologically Specific psychological interventions (e.g. one one trial desensitisation for blood/needle phobia, symptom management) New ways of working self management, education, adherence, capacity education, adherence, capacity 8

9 A model of Psychological Care in Physical Health Is it enough to focus purely on those with identified psychological disorder disorder / mental illness? Who does psychological care? What does it include? What does it include? 9

10 Broad focus all staff Consideration of all needs physical, psychological, social, spiritual Specific consideration of Psychological Issues Psychological Skills needed throughout: Communication Empathy Imagination Patience Formulation Sharper Focus Specialist psychological staff Specific knowledge 10

11 From: The Renal Team: A Multi Professional Renal Workforce Plan For Adults & Children with Renal Disease Recommendations of the National Renal Workforce Planning Group British Renal Society

12 The Components of Psychological Care (from Nichols, 2003) Level 1 (awareness) Awareness of psychological issues Patient centred listening Patient centred communication Awareness of the patient s psychological state and relevant action Level 2 (intervention) Monitoring the patient s psychological state with records kept Informational and educational care Emotional care Counselling care Support/advocacy/referral Level 3 (therapy) Psychological therapy 12

13 NICE Guidance Supportive & Palliative Care Levels of Psychological Input Level 1 (all patients) Effective information giving, compassionate, communication & general psychological support All Health & Social Care Professionals Recognition of Psychological Needs Level 2 (most patients) Crisis management/simple psychological interventions Health & social care professionals with additional expertise Screening for psychological distress Psychological techniques such as problem solving 13

14 Level 3 (1 in 4 patients) Counselling & specific psychological interventions such as anxiety management & solution focused therapy, delivered according to an explicit theoretical framework Assessed for psychological distress & diagnosis of some psychopathology Trained and accredited professionals Level 4 (1 in 10 patients) Formal & specialist psychological and/or psychiatric intervention Mental Health Specialists Diagnosis of Psychopathology Specialist psychological & psychiatric interventions such as psychotherapy, including cognitive behavioural therapy (CBT) 14

15 End of Part One End of Part One 15

16 Core Role Working with clinical teams & colleagues One to one patient work Audit & Evaluation Research Service Development

17 Working with Teams Consultancy formal or informal By being part of team discussions and decisions May follow formal assessment of patient but needn t Education/Training E.g. communication skills Assessment and awareness of psychological needs Supervision group & one to one including: Reflective practice Discussing specific concerns about patients Education about psychological issues Supportive?de briefing, stress management Interpersonal issues impinging on the work setting 17

18 Core Role Working with clinical teams & colleagues One to one patient work Audit & Evaluation Research Service Development

19 One One to to one work One off assessment to aid team s understanding & management of patients (1 2 appointments). Assessment followed by referral to another service Brief intervention (e.g. 2 appointments close together followed by a longer term follow up) Longer term psychological therapy (e.g months of more in depth psychological therapy). For example: Traumatic stress reactions, adjustment & coping Mood disturbance, anger, anxiety, phobia Behaviour change e.g. diet, adherence, activity levels Capacity, decision making 19

20 Intra organisational Partnerships Inter organisational Partnerships Within NHS Individuals: e.g. psychologists, AHPs, physicians, surgeons, nurses, SW, chaplains etc MDTs Mental Health Services / Liaison Psychiatry Primary Care Beyond NHS Core Role Working with clinical teams & colleagues One to one patient work Audit & Evaluation Research Service Development Social Services Academic e.g. DClinPsy, pre qual, CPD, research User & Community Groups Voluntary/ Private

21 End of Part Two End of Part Two 21

22 Hot Cross Bun Bun Behaviour Physical Sensation Thoughts Emotion 22

23 Psychological Needs 1 Mild to moderate distress Severe distress Depression adjustment disorders to severe clinical depression Anxiety including adjustment disorder, generalised anxiety states, phobias and panic attacks Problems with personal relationships including communication with health and social care professionals Psychosexual difficulties Psychosexual difficulties 23

24 Psychological Needs 2 Alcohol & drug related problems Personality difficulties Deliberate self harm Deliberate self Psychotic illness Organic brain syndromes Traumatisation Anger Demoralisation more subtle difficulties Cognitive functioning esp more subtle difficulties 24

25 A few theoretical health psychology issues A few theoretical health psychology issues Locus of Control Coping Style Information seeking monitors & blunters Adherence, compliance & concordance Theory of planned behaviour Theory of planned behaviour 25

26 What to be aware of in assessment What to be aware of in assessment Mood. Low, miserable, tearful or flat in mood. Alternatively look out for an unusually high, elated or euphoric mood (this may be fine but it is worth considering that it may be hiding problems). Anxiety, panic, tension. High anxiety either reported by the patient or evident from physical signs (e.g. trembling, excessive talking, questioning, sweating etc.). More extreme examples of anxiety seen in panic (hyperventilation, panic attack, palpitations etc.). Tension may be seen in posture (e.g. sitting on edge of chair), complaints of aches and pains, tension headaches 26

27 Anger, frustration. This may be completely normal but can be a major source of mood disturbance and tension and will also have an impact on relationships (both with family and staff). Is this anger well founded (e.g. have they been mucked about) or an expression of distress. Sleep. Disturbed sleep of any kind. Problems getting off to sleep, waking early, disturbed throughout night, nightmares. Why? (e.g. physical discomfort, worrying thoughts etc.). New or long standing. 27

28 Appetite. Change (increase or decrease) in Appetite appetite secondary to mood disturbance, eating disorder, body image or physical/surgical reasons. Weight loss? Energy / lethargy. Fatigue, motivation, tiredness. Pain. Related to illness/surgery or Pain otherwise. Severity, duration & location. otherwise. Severity, duration & location. 28

29 Concentration / cognition. Reported or Concentration / cognition observed memory problems, not following conversations, speech and language problems (may be related to mood and anxiety or other factors). Enjoyment / pleasure. Inability to enjoy Enjoyment / pleasure things enjoyed before. May be because of physical limitations or because of low mood. (e.g. reading, TV, social contact, hobbies, work etc.) work etc.) 29

30 Activity Levels. Look out for boredom & Activity Levels inactivity as this may be closely related to mood disturbance & anxiety. Is the inactivity realistic given the physical condition or is the patient doing less than they could. Social support and relationship issues. Social support and relationship issues Who is around to be supportive (distinguish between practical support and emotional support). Pre support). Pre existing problems. Sexual issues. issues. 30

31 Medication (especially psychotropic & opiates). Antidepressants, tranquillisers, anti opiates). Antidepressants, tranquillisers, anti psychotics, anti psychotics, anti epilepsy etc. morphine based. Side effects (e.g. hallucinations on morphine post post op, sedation) alcohol, un prescribed drug Substances alcohol, un use, tobacco Knowledge of condition, treatments & prognosis. Informational needs, gaps, desires, questions, awareness desires, questions, awareness 31

32 Premorbid personality. What was the Premorbid personality patient like as a person before the onset of their illness (e.g. always a worrier, always coped by battling on, always in control and independent etc.). It is useful to get a view of this from other people who know the patient. Body image issues. Views about changed body, reactions to changes in body appearance and/or function. Related to current condition or pre current condition or pre existing existing 32

33 Premorbid psychological problems. Premorbid psychological problems Contact with mental health professionals (psychiatry, CPN, psychologist, counsellors), previous psychiatric diagnosis, medication or admission. Anything else. Anything that you think is Anything else relevant with regard to the patient's psychological status (e.g. other sources of stress such as other family illness, financial problems etc.) problems etc.) 33

34 References White, C.A. (2001) Cognitive Behaviour Therapy for Chronic Medical Problems A Guide to Assessment and Treatment in Practice. Wiley UK. Rabindranath K.S, Daly C, Butler J.A, Roderick PJ, Wallace S, MacLeod A.M. Psychosocial interventions for depression in dialysis patients (Review). Cochrane Database of Systematic Reviews 2005, Issue 3. Art. No.: CD Nichols, K. (1993) Psychological Care in Physical Illness (second ed) Chapman & Hall. Nichols, K. (2005) Why is Psychology still failing the average patient? The Psychologist, January 2005, Kathleen McCann, K.N. & Boore, J.R.P. Fatigue in persons with renal failure who require maintenance haemodialysis Journal of Advanced Nursing, 2000, 32(5), Penkowera, L., Dewb, M.A., Ellisc, D., Sereikad, S.M., Kitutue, J.M.M. & Shapirof, R. (2003) Psychological Distress and Adherence to the Medical Regimen Among Adolescent Renal Transplant Recipients. American Journal of Transplantation : Watson, A.R. (2005) Problems and pitfalls of transition from paediatric to adult renal care Paediatric Nephrology (2005) 20: Hutchinson, T.A. (2005) Transitions in the lives of patients with End Stage Renal Disease: a cause of suffering and an opportunity for healing. Palliative Medicine : 270/277 34

35 The End The End 35