what is clinical psychology? - unibg. bergamo... · graded exposure, relaxation, stress...
TRANSCRIPT
A modern introduction to clinical psychology on the ground…..
• Delivering clinical interventions
• Supervision
• Consultation
• Leadership
• Training
• And research, in changing health and social care services
• The voice of the users of these services
A modern introduction……
• Using psychological theory and research to understand and help alleviate human distress
• Assessment, formulation, intervention and evaluation
• Different specialties • Range of work: direct/indirect; group work;
organisational development; service evaluation…….
• The therapeutic alliance • Multi-disciplinary teams
Multi-disciplinary teams
• Rationale
• Staff support, training and supervision, team development, team formulation, reflective practice sessions, leadership
• Team dynamics: competition, professional rivalries, different approaches to understanding and treating emotional distress, struggle to understand and value different perspectives
• Team effectivesness: role clarity and respect, shared goals and culture of care = creativity
Clinical psychology does not stand still
• Talking therapies and psychologically aware services are what the users of mental health services want, and need
• Active collaboration, trust and emotional safety
• Research evidence offers a clear mandate to expand the availability of psychological interventions
• Developing and delivering the best care requires competencies in research, teaching, supervision and consultation
Formulation
• Connections between assessment information and psychological theory and research: collaborative formulation
• Basis for decisions about helpful interventions • Progressive hypothesising: pre-disposing, precipitating,
maintaining and protective factors • Major models: behavioural, cognitive-behavioural,
psychodynamic and systemic • Empirically supported treatments, evidence-based
practice and practice-based evidence • Integrative practice
Behaviour Therapies
• Focus on overt and measurable behaviour
• Learning theories – classical and instrumental conditioning – positive and negative reinforcement, punishment
• Maladaptive anxiety develops through classical conditioning, maintained through instrumental conditioning ie avoidance
• Here and now focus – learn new associations – graded exposure, relaxation, stress innoculation training, behavioural activation, problem solving
Cognitive Behaviour Therapies
• Subjective thoughts/perceptions direct impact on behavioural and emotional state
• Psychological disturbance unhelpful ways of viewing self, world and future
• Cognitive processes accessible, so have potential to change them; meaning given to a situation determined by beliefs/schemas – also accessible to change
• By, learning to identify unhelpful beliefs, reviewing and testing alternate beliefs, possible to change beliefs serving to maintain and trigger symptoms
Psychodynamic Therapies
• Short term approaches
• Focus on ways in which emotional and relational dynamics set up in early life come to be replayed in ways that are unhelpful/give rise to psychological symptoms
• Early life experiences with caregivers give rise to internalised models and behaviours about what it takes/means to remain connected to that caregiver (AF)
• Adaptive in childhood – survival – in adulthood may interfere with trust and intimacy – repeating patterns
• Insight oriented – understand patterns, integrate experience into conscious awareness
Systemic Therapies
• Many different schools of systemic therapy
• Relationship dynamics and experiences give rise to psychological distress
• Significance of context, pattern and process
• GGRRAACCEESS
• Intervention with relationships
• Working ‘within’ and ‘between’
• Integrated formulation
Choice of Therapy
• Why might we choose an alternative intervention over an empirically supported treatment:
• Client informed choice
• Good attempts at previous EST not successful
• Problems of greater concern may best be addressed by a different therapeutic approach eg working with violence in relationships
Three Frameworks
• Scientist-practitioner
• Reflective-practitioner
• Critical-practitioner
Reflective practice
• Reflective practitioner: reflection in action; reflection on action – reflecting on learning, emotional responses, ideas and theories that guide action – insight for improved action in the future
• Continuing professional development
• Life long learning
• Reflective supervision
• Self of the therapist
• Taking care of ourselves and each other
Critical Practitioner
• Social constructionism – use of language: how it has maintained power and authority within and between professions
• Critique of psychiatric diagnosis versus formulation
• Recovery oriented practice and quality of life
• Social inequalities and relationship with well being
• Social exclusion and social connections
Scientist Practitioner
• Application of research evidence: randomised controlled trials (efficacy); effectiveness trials; case series; experimental research; cost-effectivesness research
• Credibility of the profession?
• Limitations of the evidence base
• Good reasons for choice of alternative therapy?
• Clinical wisdom – best available research evidence – client preference
Drawing on the three frameworks in clinical practice
• Good understanding of what works and the evidence base
• Tailor our approach to unique circumstances of client/family
• Avoid imposing own cultural values and worldview
• Create space to reflect on what we are doing and learn for the future
• Evaluate work on an ongoing basis using valid measures/feedback processes
The Bio-Psycho-Social Model
• Biological: genetic predispositions, neurochemistry, effect of medications, immune response; fight-flight-freeze responses, physiological responses
• Psychological: learning, emotions, cognition, memory, perceptions, beliefs, values, coping, biofeedback, exercise
• Social: social support; attachment and inter-personal relationships, cultural traditions, family and kin, poverty and discrimination, social class, faith, social and health care systems
Understanding Trauma Responses
• Fight, flight and freeze
• Brain systems involved in emotion regulation
• Dissociation and social isolation
• Social engagement system: non conscious relational responding; interactive regulation
• Addictions and self harm: attempts to cope with unbearable emotion and numbing
• Emotional safety in relationships
• Trauma changes brain development, self-regulation and capacity to stay focused and in tune with others
Helping with Trauma Responses
• What are people trying to cope with? • What are their internal/external resources? • How do they calm themselves down? • Do they have caring relationships with their own
bodies? • What do they do to develop a sense of agency,
vitality and relaxation? • Do they have emotionally salient interactions
with others? • Do they have a sense of purpose?
Helping with Trauma Responses
• Who really knows them? Listens to them? Loves them? Cares for them?
• Who do they turn to for comfort? • Who looks after them when they are ill? • Are they members of a community? • Do they play a vital part in the lives of the people
around them? • What skills do they need to focus, pay attention, and
make choices? • What are they good at? • How can we help them feel in charge of their lives?
Future Directions
• Understand and support communities • Help develop ‘healthy’ organisations • Enable teams and networks to promote
psychological well being • Recognise and work with the crucial role of
families and attachments in the development of emotionally robust communities
• Work with people with complex mental health difficulties who have not responded to psychological therapy
Future Directions
• Develop service initiatives to support the growing population of people with long term neurological and physical conditions, and their carers
• Develop supervision and reflective practice systems to help staff and services remain compassionate when they are under threat
• Produce research and training to help others advance knowledge of, and capacity to intervene in, all of the above
Some reading…..
• Davey, G., Lake, N. & Whittington, A. (eds) (2015) Clinical Psychology. Second edition. London: Routledge
• Dallos, R. and Vetere, A. (2009) Systemic Therapy and Attachment Narratives. Applications in a range of clinical settings. London: Routledge
• Johnstone, L. and Dallos, R. (eds) (2006) Formulation in Psychology and Psychotherapy. London: Routledge
• Van der Kolk, B. (2014) The Body Keeps the Score. Second edition. Penguin Books