Clinical skills in the Psychosocial Interventions Pathways

Steve Wood

Pathways Leader

Clinical guidelinesFinancial imperatives

Cognitive & behavioural models Current skills of mental health nurses

Acquisition of skills Our approach

Rationale for acquisition of cognitive behavioural skills by

mental health nurses

Clinical Guideline 1December 2002Developed by the National Collaborating Centre for Mental Health

SchizophreniaCore interventions in the treatment andmanagement of schizophrenia in primaryand secondary care

Psychological treatments –

•CBT

•Family work

Anxiety

Clinical Guideline 22December 2004Developed by the National Collaborating Centre for Mental Health

AnxietyManagement of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care

Panic disorder –

•CBT

•Self-help based on CBT

Generalised anxiety –

•CBT

•Self-help based on CBT

Depression

Clinical Guideline 23December 2004Developed by the National Collaborating Centre for Mental Health

DepressionManagement of depression in primary and secondary care

Mild –

•Self-help based on CBT

•Problem solving therapy

•Brief CBT/counselling

Moderate to severe –

•CBT

•Interpersonal therapy

•Antidepressants

Treatment resistant, recurrent, atypical –

•Combined CBT/antidepressants

PTSD

Post-traumatic stressdisorder (PTSD)The management of PTSD in adults andchildren in primary and secondary care

Clinical Guideline 26March 2005Developed by the National Collaborating Centre for Mental Health

PTSD –

•Trauma focused CBT

•Eye Movement Desensitisation & Reprocessing (EMDR)

•Antidepressant – NOT as first line

OCD

Clinical Guideline 31November 2005Developed by the National Collaborating Centre for Mental Health

Obsessive-compulsive disorderObsessive-compulsive disorder: core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder

OCD & BDD –

•CBT – individual or group

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RATIONALES FOR SaFF TARGETS2006/2007

Why bother?

Trusts are beginning to be audited in terms of compliance with NICE guidelines and will face financial penalties for failing to comply

SaFF targets 14 & 15

Who will carry out all these “psychological”

interventions?

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Cognitive model

• Principles– people’s view of their

world is determined by their thinking (cognition)

– cognition influences emotions, behaviour and attitudes

– impaired/dysfunctional cognition creates mental pathology

– significant change in mental disorder needs to involve significant change in cognition

• Characteristics– treatment involves

“collaborative empiricism”– client active participant in

assessment e.g. diaries– gives client sense of

mastery over feelings thought to be beyond voluntary control

– interpretation of thoughts is main determinant of action

Behavioural model

Behavioural model

• Principles– symptoms and behaviour

constitute main feature of mental illness

– origin and persistence of symptoms of behaviour can be understood through science of learning theory

– application of learning theory removes maladaptive symptoms and in so doing cures the disorder

• Characteristics– person’s behaviour part

of own responsibility

– treatment aims to extinguish maladaptive conditioned response

– behaviour programmes based on functional analysis

– non-hierarchical

– treatment contracts must be voluntary

Medical model

Contrast with medical model …

• Principles– mental pathology also

accompanied by physical pathology

– mental illness can be classified as different disorders which each have common features

– mental illness is biologically disadvantageous and handicapping

– causes of physical and mental pathology in psychiatric illness all explicable in terms of physical illness

• Characteristics– patient passive recipient of

treatment

– if patient fails to respond - more powerful treatment or question diagnosis

– doctor is expert, chief decision maker and head of the team

– “logical”

– “scientific”

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Journal of Advanced NursingVolume 27 Page 253  - February 1998

doi:10.1046/j.1365-2648.1998.00516.xVolume 27 Issue 2  The clinical skills of community psychiatric nurses working with patients who have severe and enduring mental health problems: an

empirical analysis Sheila M. Devane DClin Psychol, Gillian Haddock PhD, Stuart Lancashire MSc, Ian Baguley RMN, Tony Butterworth

PhD, Nicholas Tarrier PhD, Abigail James BSc & Phillip Molyneux MSc AbstractThis study describes the use of reliable scales to rate the clinical skills of mental health nurses when working with individuals and families with severe mental health problems. The Cognitive Therapy Scale and the Schizophrenia Family Work Scale were adapted for the study and were shown to have good inter-rater reliability when assessing audio-taped interviews carried out by mental health nurses during their usual course of work with patients with severe mental health problems and their families. The sample of mental health nurses studied were shown to have significantly better general therapy skills than specific cognitive therapy technical skills. The implications for training are discussed.

• Significant difference between general and technical skills

• Good on understanding, empathy and professional manner

• Moderate on questioning

• Poor on specific cognitive behavioural skills

– pacing and use of time– collaboration– guided discovery– agenda setting

• Very poor on– feedback – conceptualising problem– setting goals– implementing goals– negotiating homework

Do nurses have the skills?

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How are skills acquired?

• Nature of “skill”

• How skills are learnt

• Micro-skills

• Combining micro-skills

• Stages of skills acquisition

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Our approach

• 4 stages1. Priming

2. Building confidence/allaying anxiety

3. Enhancing skills

4. Real-life practice

• Feedback

• Questioning

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