Designing a CBT Service
for an Acute In-patient
Setting:
A pilot evaluation study.
Caroline Durrant, Isabel Clarke,
Abigail Tolland and Hannah Wilson
Clinical and Assistant Psychologists
from AMH Woodhaven.
The challenge of therapy delivery
Variable and unpredictable admission
times
Mixed diagnoses
Time of crisis
Risk factors
The challenge of working with
the system
Combining psychological with
medical approaches
Developing therapeutic skills across
the board
Having an impact on milieu and
morale
The challenge of evaluating the
work.
Finding a way to measure the impact of the
psychological therapy; routine
interventions also contribute to symptom
change, therefore before and after
symptom measurement is not indicative of
effectiveness.
The Challenge of Therapy Delivery.
The key features of the Woodhaven therapeutic approach
are as follows:
 Simple formulation based on relationship to emotion,
informed by the ICS split between the emotional and
logical systems. (Interacting Cognitive Subsystems:
Teasdale & Barnard 1995)
 A “Third Wave” Cognitive therapy – focus on intervening
between thought and feeling rather than altering thought
to effect feeling (Hayes et al. 1999)
 Management of arousal (breathing control), and
mindfulness training to facilitate intervention in the
cognitive/emotional process.
Therapy approach continued
 Techniques of meeting, expressing and letting
go of emotion as opposed to the previous
avoidance.
 This draws on Linehan's (1993) approach and
has similarities to Emotion Focused Therapy
(Greenberg 2002).
 Practical discussion of lifestyle management to
ensure the continuation of a better adjustment.
 All these features are designed to enable
someone to take control of their own recovery –
in sympathy with the Recovery Approach (e.g.
Repper & Perkins, 2003).
Typical formulation
PAST ABUSE
LOSSES
PARTNER LEAVING
Nightmares: can’t sleep
Cut self
Attempt suicide
FEAR
RAGE
SADNESS
More difficult to cope
Friends and family alarmed.
Could lose custody of
children.
Avoid going out and seeing
people
Feel worse
More time to brood
WAYS FORWARD
Don’t let the feelings be in control: YOU ARE IN
CHARGE
Do things despite the feeling
Breathing and mindfulness to get back to the present
Use the energy of the anger positively
Psychological Therapies at Woodhaven:
wider role
The other activities of the Woodhaven Psychological
Therapies Service complement the individual therapy
delivery and will contribute to the outcomes.
• Work with staff and the institution
• DBT programme, involving a multidisciplinary team, and
delivering a cross diagnostic group programme
• Other psychological group programmes: A
compassionate mind approach to self esteem: ‘The
Making Friends with Yourself group’, and a psychosis
group: ‘The What is Real and What is Not Group.’
• An anxiety and stress management programme to be
delivered by nursing staff following training.
Working with staff
 Weekly Reflective Practice Groups for each
ward, for the nursing staff, facilitated by a
psychologist.
 Co-facilitated, multi-disciplinary group work with
a psychological focus.
 Psychology-led training for staff group on
developing strengths based care planning for
the most challenging clients.
 Training has lead to request for regular multidisciplinary care planning meetings (to be
implemented)
Development of a DBT in-patient service
 A psychology led, multi-disciplinary team at Woodhaven
are trained in DBT. The team are implementing an
adapted programme for the unit which includes:
 6 week Emotional Coping Skills (ECS) group
 Chain analysis after incidents of self harm
 1:1 weekly therapy following the DBT model and
Individual skills training for BPD individuals with
extended stay on the Unit.
 Risk management advice
 Staff training and education
 Consult team for support and supervision
Evaluation of the Individual Therapy
Service.
This was set up by Caroline Durrant (Assistant
Psychologist), and conducted while she was with
us (between September 2004 and March 2005).
The period measured intensively was short
because of the short duration of this support.
We only managed to collect 16 completed data
sets during this period – usual problems with
Time 2 data collection…….
Abigail Tolland (who worked briefly with us as an
honorary assistant psychologist), assisted with
the analysis of the data.
Principles behind design of the
evaluation.
 Designed to measure the intervention described
above.
 Measurement of symptom change not useful for
evaluation because of concurrent interventions
(medication etc.).
 Self efficacy and management of emotions are
the aims of the intervention, hence they are
evaluated.
 Measurement of individual Goal achievement.
Measures
1. CORE - to measure level of psychopathology rather
than change.
2. Mental Health Confidence Scale (MHCS)
(Carpinello, Knight, Markowitz & Pease, 2000)
The MHCS measures self-efficacy in relation to mental
health.
3. Locus of Control of Behaviour Scale (LCB)
(Craig, Franklin & Andrews, 1984)
The LCB scale is a seventeen item scale focusing on
perceived control over mental health problems.
4.Goal Setting: Visual-analogue, ideographic, measure of
individual goals.
5. Living with Emotions
The Living with Emotions measure was designed for this
research. It consisted of three questions looking at
confidence in coping with emotions.
Mental Health Confidence Scale
70
60
Pre
Post
50
40
S c or e
30
20
10
0
Tot al score **
Opt imism
Coping **
Advocacy
Locus of Control
50
Pre
40
Post
30
S c or e
20
10
0
Int ernal **
Ext ernal
Living With My Emotions
20
Pre
15
Post
S c or e
10
5
0
Conf idence **
St rat egies **
Goal Setting Questionnaire
10
Pre
Post
S c or e
5
0
Client’s perception of how close they were
to reaching their goals **
Results
Pre and post therapy scores suggest that service
users felt:
 more able to cope with their mental health difficulties
 had a greater internal sense of control
 felt more confident in dealing with their emotions
 felt more confident in employing strategies to deal
with strong emotions.
Keeping up the Evaluation
Measurement has continued, but without an
assistant, data collection has been harder
to maintain consistently. Results since the
end of the study continue to be
encouraging.
A summary follows.
Locus of Control Scale: Most recent results,
n=24
56
55
54
Mean total scores
53
52
51
Series1
50
49
48
47
46
Before
After
Mean total LOC scores, (lower= higher internal LOC)
Significant difference t=2.39, p<0.025
Living with emotion scale (Confidence): Most
recent data, n=37
20
18
16
mean scores
14
12
10
Series1
8
6
4
2
0
Before
After
LWE score, significant difference, t=2.97, p<0.005
Locus of Control Scale: Most recent
results, n=24
c
56
55
54
Mean total scores
53
52
51
Series1
50
49
48
47
46
Before
After
Mean total LOC scores, (lower= higher internal LOC)
Significant difference t=2.39, p<0.025
SUMMARY AND CONCLUSIONS
1. Psychological services can contribute to
developing a therapeutic milieu in an in-patient
acute setting in a number of ways:
staff support and training
reflective practice,
on-going supervision,
group and individual therapy
2. Service users report increased confidence and
coping after very brief psychological therapy
Directions for the Future
1. Ongoing evaluation of the brief individual therapy.
2. Working with new teams: The same model is being
extended to Crisis Resolution Home Treatment and
Assertive Outreach Teams and will be evaluated. This
will facilitate smoother psychological working across
discharge.
3. Evaluation of the impact of these approaches upon on
re-admission rates over time.
4. Continuing development of the multidisciplinary DBT
programme, its evaluation and application across
diagnoses.
5. Evaluate the impact of psychology led reflective practice
on nursing practice, staff morale, ward atmosphere etc.
6. Evaluate the impact of psychology led training on ward
practice.
Contact Details and References
• [email protected]
• [email protected]
• Durrant, C., Clarke, I., Tolland, A. & Wilson, H.
Designing a CBT Service for an Acute In-patient
Setting:A pilot evaluation study. Clinical
Psychology and Psychotherapy. 14, 117-125.
• Forthcoming book: ‘Cognitive Behaviour
Therapy for Acute Inpatient Mental Health Units;
working with clients, staff and the milieu’. Edited
by Isabel Clarke & Hannah Wilson. Routledge.
Isabel’s website: www.scispirit.com/Psychology/