Chapter 1
Introduction
Isabel Clarke
The case for optimism
Therapy, and indeed any service provision, is about offering hope. There is a problem; but something can be done about it. Hope is one of those powerful but hard to pin down non-specific factors that so complicate the search for the âactive ingredientsâ in the evaluation of particular therapies. Hope is first on the list of factors promoting recovery that came out of the studies of Ohio and Maine service users that have been the foundation of the Recovery movement in mental health (Ralph et al. 1996, quoted in Allot et al. 2002).
This book is about hope for the role of psychological therapy in general, and cognitive behaviour therapy (CBT) in particular, in the acute mental health inpatient unit. It is about challenges and difficulties, but with the emphasis on how these can be overcome; how creative innovation, and sound multidisciplinary co-operation can meet the challenges. The greatest challenge to the provision of psychological therapy in the inpatient environment is the sense that it cannot be done, or that it is somehow not worth it. Marie, who has experienced the services first hand over many years, explains eloquently in Chapter 4 why it is worth it and why it must be done. Other chapters in the book look at the way in which the culture of service provision is changing to make putting psychological therapy at the heart of inpatient provision possible and achievable (Chapter 2, John Hanna, and Chapter 3, Peter Kinderman). The rest of the book essentially demonstrates how this can be done, whether through direct provision of therapy, or working through and developing the therapeutic skills of the staff group.
A clash of cultures
The encounter between cognitive behaviour therapy and the acute inpatient unit inevitably entails a clash of cultures. Therapy is about introducing order into the chaos of human emotions and human relationships. All therapies stress orderly induction into therapy and progress through it. Providing space for cool reflection is of the essence. CBT adds to this the discipline imposed by science. Predictable conditions are a prerequisite for repeatability. The acute psychiatric hospital by contrast must contain crisis and unpredictability. There is no filtering of admissions by diagnostic group or anticipated length of intervention. The service is needs led, and at the sharp end of need.
Then there is the matter of fundamental philosophy. The inpatient unit is the last bastion of the medical model in its pure form. Community teams, rehabilitation units and forensic services might offer multidisciplinary services with a plethora of therapeutic approaches, but the hospital has traditionally been seen as somewhere for the person at risk and in acute crisis to receive medication, be stabilized, and return to the care of the community services.
Why CBT?
Why then should the CBT therapist wish to venture into this potentially unpromising and even hostile territory? There are several reasons. The first is to do with the people the hospital serves. Mental breakdown is not such an uncommon event in peopleâs lives. The lifetime prevalence of admission is high. Few people will not know someone who has been admitted to a psychiatric hospital. As human beings, all these people will have a need to make sense of an experience which has probably seen the planned course of their life come to a shuddering halt. Indeed, surveys of patient opinion about mental health services in general and hospital services in particular regularly and loudly make the plea for more talking therapies.
This is true of many but not all hospital admissions. For others, they have accepted the explanation of their problems offered and are content with it. They have an illness with an impressive sounding name, and the medication (or electro convulsive therapy, ECT) offered by the doctor will cure it. This can work well for the first few admissions, but for repeat users of the service, this conceptualization can be a barrier to adaptation, and the CBT therapist has a role in persuading the, possibly reluctant, individual that they have a vital role to play in the process. There is a parallel here with the Recovery notion of The Turning Pointâ (see Allott et al. 2002; Repper and Perkins 2003) which will be covered in Chapter 6.
These reasons for CBT in the inpatient setting focus on the needs of the individual. What about the needs of the institution itself? If hospital admission represents a crisis in someoneâs life that requires reflection and reappraisal, it could also be argued that the institution itself is in crisis, and could similarly use reflection and reappraisal. This is not a new idea. Bob Hinshelwood (Hinshelwood and Chiesa 2001) argued that institutions, left to themselves, operated in an anti-therapeutic way as a defence against anxiety, and he was influential in the therapeutic community movement as a result. Considerable though the achievements of this movement have been, it has not made a major impact on the average inpatient hospital. This book will argue that the CBT therapist is in perhaps the best position to make that impact.
The acute inpatient problem
The account that follows describes UK health services as that is the location of the contributors to this volume, but it is likely that there will be parallels with the situation in other countries. Acute psychiatric inpatient units in Britain have not been receiving a good press. The 1998 Sainsbury Centre report (SCMH 1998), and the Department of Health sponsored document that followed it (DH 2002b), spell out the familiar criticisms, of lack of privacy and dignity, lack of safety, and lack of therapeutic input. Service user forums such as Asylum and Mind reiterate these complaints, and demonstrate time and again that people in crisis want someone to talk to: someone to take their predicament seriously and help them to make sense of it. There are, of course, exceptions and developing good practice. The various chapters of this book illustrate this, and John Hannaâs Chapter 2 outlines the initiatives to raise standards. Unsurprisingly, staff morale in the acute inpatient sector mirrors user dissatisfaction, as evidenced by the crisis in nurse recruitment. The exceptions, and developing good practice, cannot alter the high probability that someone accessing such a service at a time of personal crisis, at an arbitrary location in Britain, will find it a less than truly therapeutic experience.
There is a context to this depressing picture. More widely, mental health services have seen dramatic development over the last ten years. First came the establishment of community mental health teams; then the assertive outreach teams were set up, and most recently, crisis resolution and home treatment teams. At the same time, much thought has been put into secure services, with the development of new medium and low secure units. Apart from the addition of psychiatric intensive care units (PICUs), all these developments have tended to impact negatively on the traditional acute psychiatric inpatient unit by concentrating within its walls those whom nobody can manage outside, and by poaching some of the more adventurous staff.
However, most people who experience acute breakdown, or ongoing major psychiatric problems, tend to end up in hospital at some time or another, and many are repeat users of this service. The 2004 Mind survey estimated 37, 996 people at one time in this position. Their experience and the support they receive at this time can be crucial in terms of the impact that their breakdown has on the course of their life, and unfortunately there is much evidence to suggest that this impact can be negative. Trends in the wider society have not helped, with increased alcohol and drug use leading to disinhibited behaviour, and the prevalence of family and relationship breakdown eroding natural social supports for those who are struggling.
The development of CBT approaches to severe mental health problems
Over the same period, cognitive behaviour therapy has seen dramatic spread and development. The approach allies itself naturally with a scientific, experimental stance, and has benefited from a strong research base. The therapy has therefore been perfectly placed to take advantage of the move towards evidence-based practice in the UK. The National Institute for Clinical Excellence (NICE) guidelines recognize CBT as a treatment of choice for a wide variety of conditions, ranging from depression, through post traumatic stress disorder (PTSD) to schizophrenia. Community mental health teams and the newer teams listed above routinely employ CBT therapists, or clinical psychologists with a CBT background. It is becoming accepted that this therapy should be available to clients of these services, and that the staff team should have access to the specialized assessment and formulation skills offered by the clinical psychologist.
At the same time as CBT was becoming more widespread, major developments have taken place over the last 15 or so years to develop the approach for application to more serious disorders, such as personality disorders and psychosis. Partly this has been achieved by elaborating the model, as with the development of schema focused cognitive therapy (Young 1994) and partly by looking beyond CBT, and adopting or partially adopting approaches from humanistic and psychodynamic therapies, such as emphasis on the therapeutic relationship, transference and countertransference, and a recognition of the importance of past history to present pathology. Recent developments have seen a more dramatic departure in the model, characterized by one of its exponents (Steve Hayes) as âThird Wave CBTâ. The first wave was traditional Beck and Ellis, and the second, the schema-focused approach.
In the third wave paradigm the route to change lies not so much in altering thought to alter feeling, but in altering the personâs relationship to both thought and feeling. Mindfulness is the key means, common to these therapies, to effect this. Prominent examples of these new therapeutic approaches are: mindfulness-based cognitive therapy for preventing relapse in depression (Segal et al. 2000); Linehanâs (1993a, 1993b) dialectical behaviour therapy (DBT) for borderline personality disorder, with a particular emphasis on the control of self-harm; and Steve Hayesâ acceptance and commitment therapy (Hayes et al. 1999). Paul Chadwick and others have developed and researched mindfulness groups for voice hearers (Chadwick et al. 2005), so applying it to psychosis. Other applications continue to be tried out, researched and published all the time.
As well as introducing the emphasis on mindfulness, the third wave approaches also soften the boundaries between CBT and other therapeutic approaches. In a similar spirit, while primarily focused on CBT, this book does not leave out of consideration other modalities that have much to offer in this field. Specifically, systemic thinking has contributed greatly to our understanding of institutions and team working, and a number of contributors reference this contribution. Cognitive analytic therapy (CAT) ways of using the reciprocal role to understand the transferability of patterns of relating, when working with staff teams in formulating individuals who represent a challenge to the team (Ryle 1995, 1997), fit well with the CBT model. John McGowan in Chapter 9, for instance, includes CAT in his examples of practice.
Innovation in CBT and inpatient services
From this account it would appear that the groundwork is laid for a CBT-led therapeutic revolution in inpatient services. Effective approaches are being developed and researched for the major diagnostic groups represented in the inpatient population: severe recurrent depression; psychosis; self-harm and personality disorder. However, this development is not necessarily taking place. DBT is being widely applied in inpatient settings, but for the most part these are specialist units for people in need of secure accommodation, or for specific problems such as eating disorders. The Thorn initiative which trains nurses in psychosocial, family and some CBT for psychosis has had as much or more impact on community services as in the acute hospital.
There are reasons for this, and they are to be found in the particular challenges faced by the therapist working in the general acute inpatient setting. These challenges are examined below, and creative ways of meeting them form the main subject matter of the book. However, on a more optimistic note, change is in the air. CBT therapist and clinical psychologist posts are being created specifically for inpatient units. In the part of the UK with which I am familiar, Hampshire, this has been a rapid development taking place over the last two or three years. The Workforce Development Consortium has identified acute hospitals as an area for the expansion of clinical psychology services. Thorn-trained nurses are having their impact in the sector, and the development of the new post of trainee mental health practitioner, specifically in order to marry the number of psychology and social science graduates wanting to work therapeutically in the health sector with the unmet demand for more therapy from service users, is having its effect. Peter Kinderman covers these developments in Chapter 3.
Even in the area of management of aggression and risk, where hard-line attitudes have traditionally prevailed, the latest message from government advisors is in line with the approach that CBT has to offer. The NICE guidelines (2005c) on the management of risk and aggression state:
The primary focus when dealing with aggressive behaviour should be that of recognition, prevention and de-escalation in a culture that seeks to minimize the risk of its occurrence through effective systems of organizational, environmental and clinical risk assessment and management. This approach should also promote therapeutic engagement, collaboration with service users and the use of advanced directives.
The same guidelines identify the issues that influence the development of violent incidents as âlack of opportunity to participate in therapyâ and âpoor staff attitudesâ. Suzanne Sambrook says more about this in Chapter 11.
So the need for a CBT-based philosophy throughout the operation of the institution has been recognized, but institutions are notoriously resistant to change. One or two individuals with extra training in the middle of a team working with a different ethos and a different model cannot be expected to make an automatic impact. All too often, what results is rapid disillusionment and demoralization as specialist skills are not utilized, possibly devalued, and they are expected to fulfil the same role as the rest of the team. Changing the culture so that it is supportive of therapeutic approaches and providing the necessary supervision and development opportunities for practitioners with some CBT skills is another element to the challenge for CBT in the acute hospital.
Facing the challenge
The challenge referred to by the section title can be broken down into: the challenge for individual therapy work; the challenge for effective evaluation of this work, and the wider challenge of having a real impact on the culture of the unit, and on the morale of the multidisciplinary staff group in general. Understanding the nature of these difficulties goes a long way to explaining why CBT, with its runaway success in other areas, has so far failed to have a comparable impact in this sector. This understanding is also the first step to pointing the way towards effective CBT service delivery for inpatients, and arising out of that a more therapeutically oriented acute hospital. It is the aim of this book to assist in laying the foundations for these developments.
The acute hospital setting undermines the attempt to deliver traditional CBT therapy in a number of ways. There is the unpredictability of length of stay, which can be very short. People characteristically arrive at the hospital in a state of crisis, which is in itself a therapeutic challenge, and once the crisis has abated are discharged to make room for the constant pressure of new admissions. There is the complete mixture of diagnostic groups, with frequent uncertainty about diagnosis. Where CBT protocols are linked to particular diagnoses, this presents a problem. The potential for a clash of philosophy where the medical model reigns supreme has already been referred to, as the CBT therapist attempts to formulate the problem from a different angle. This volume will expound new developments of the CBT model, arising naturally from the current âthird waveâ climate as outlined above, to meet these challenges, as well as demonstrating how CBT can be introduced acceptably to influence the whole ward culture through the judicious use of reflective practice groups (Chapter 10), training (Chapter 12) and supervision initiatives.
