Therapeutic Alliance with the whole team

1. Therapeutic Alliance with the whole team Isabel Clarke Consultant Clinical Psychologist

2. The gap between the team and the therapist Therapist • Psychological approach • Listens • Makes sense – formulates • Collaborative • Holds hope and strengths • Challenges – facing feelings • Changing behaviour patterns • Team • Medical approach • Diagnosis • Risk assessment • Patient = passive recipient • Focus on pathology • Treatment to eliminate suffering • Behaviour change should follow. • Legal controls if it doesn’t

3. Tensions between therapist and team • Good cop/bad cop (can go either way) • Therapist ‘upsetting’ patient, increasing risk • Medication or ECT interfering with therapy • Symptom elimination v quality of life – Recovery goals • Therapist doing mysterious things. Team feel disempowered. • Apparent ineffectiveness of therapy cf. rapid effects of medication

4. Time for a holistic approach • Both service users and medical staff want to move beyond the purely medical. • Recovery • Need to extend the collaborative, therapeutic approach to the team • Preserve accurate empathy • Strip away assumptions • Factor in trauma

5. Aims • To give the service user in crisis the following hopeful Recovery message: • Their distress is understandable and taken seriously • Their central role in making things change is demonstrated. • To teach new ways of coping and support the use of these skills. • To enable all staff to work with the psychological model, through training, supervision and support from the therapy service.

6. Different Circuits in the Brain (Adapted from DBT) EMOTION MIND REASONABLE MIND WISE MIND Reasonable Mind Memory Emotion Mind Memory IN THE PRESENT IN CONTROL

7. Ideas to think about • When something has gone wrong, each one of us will experience a horrible feeling. • How do you deal with a horrible feeling? • What do you feel like doing about it? What do you actually do? • If the feeling was there all the time, and you kept reacting to it like that……..what would happen? • What might this say about symptoms?

8. Emotion and Behaviour Based Formulation Template (Comprehend, Cope and Connect) Past: abuse, trauma etc. Recent triggering event Try to escape from the emotion by avoidance, self harm etc. Feel better short term Horrible Feeling Another maintaining cycle feeding the emotion Bad longer term consequences. Aversive emotion worse.

9. Skills teaching and coaching – a team response • Staff trained, supported and supervised to deliver basic psychological strategies to break the cycles • Programme of psychologically informed group work. • Regular mindfulness sessions. • Individual coaching on the ward or by Hospital at Home staff. • Including carers, partners etc. where relevant

10. Contact details, References and Web addresses • Isabel.Clarke@southernhealth.nhs.uk: isabel@scispirit.com • Araci, D & Clarke, I (2016): Investigating the efficacy of a whole team, psychologically informed, acute mental health service approach, Journal of Mental Health, DOI: 10.3109/09638237.2016.1139065 Clarke, I. (Ed.) (2010) Psychosis and Spirituality: consolidating the new paradigm. Chichester: Wiley • Clarke, I. ( 2008) Madness, Mystery and the Survival of God. Winchester:'O'Books. • Clarke, I. & Wilson, H.Eds. (2008)Cognitive Behaviour Therapy for Acute Inpatient Mental Health Units; working with clients, staff and the milieu. London: Routledge. • Durrant, C., Clarke, I., Tolland, A. & Wilson, H. (2007) Designing a CBT Service for an Acute In-patient Setting: A pilot evaluation study. Clinical Psychology and Psychotherapy. 14, 117-125. www.isabelclarke.org