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Clinical
Psychology
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This new edition of Clinical Psychology offers an expansive and up-to-date introduction
to the field. Written by clinical practitioners and researchers, and supported by the
personal stories of service users themselves, it provides a uniquely balanced view of
contemporary clinical psychology.
Extensively revised throughout, the book explains the core principles of clinical
practice, as well as outlining the role of a clinical psychologist within a healthcare team.
It covers issues involved in working with children and families, adult mental health
problems, people with disabilities and physical health issues, and the use of neuro-
psychology. The final part of the book looks at both the history and future of the
discipline, as well as professional issues in the field, and career options for those wishing
to pursue their interest further.
Its integrated and interactive approach, combining the perspectives of professionals
with the people they treat, make this book the ideal companion not only for under-
graduate courses in clinical psychology, but also for anyone interested in a career in
this field, including a range of healthcare professionals.

Graham Davey is Professor of Psychology at the University of Sussex and former

President of the British Psychological Society, UK.

Nick Lake is Senior Clinical Director and a Consultant Clinical Psychologist at Sussex
Partnership NHS Foundation Trust, UK.

Adrian Whittington is Director of Education and Training and a Consultant Clinical

Psychologist at Sussex Partnership NHS Foundation Trust, UK.
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7KLVSDJHLQWHQWLRQDOO\OHIWEODQN
 Clinical
Psychology
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Second edition

Edited by
Graham Davey,
Nick Lake and
Adrian Whittington
 Second edition published 2015
by Routledge
27 Church Road, Hove, East Sussex BN3 2FA
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2015 Graham Davey, Nick Lake and Adrian Whittington
The right of the editors to be identified as the authors of the editorial
material, and of the authors for their individual chapters, has been asserted
in accordance with sections 77 and 78 of the Copyright, Designs and
Patents Act 1988.
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All rights reserved. No part of this book may be reprinted or reproduced

or utilised in any form or by any electronic, mechanical, or other means,
now known or hereafter invented, including photocopying and recording,
or in any information storage or retrieval system, without permission in
writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and explanation
without intent to infringe.
First edition published by Hodder Education 2008
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Clinical psychology / edited by Graham Davey, Adrian Whittington,
Nick Lake. — Second edition.
pages cm. -- (Topics in applied psychology) 1. Clinical psychology.
I. Davey, Graham, editor. II. Whittington, Adrian, editor. III. Lake,
Nick (Clinical psychologist) editor.
RC467.C5868 2015
616.89--dc23
2014035042

ISBN: 978–1-84872–222–4 (hbk)

ISBN: 978–1-84872–221–7 (pbk)
ISBN: 978–1-31572–356–3 (ebk)

Typeset in Bembo and Univers

by Florence Production Ltd, Stoodleigh, Devon, UK

Additional materials are available on the companion website at www.routledge.com/cw/TAP

 Contents

Contributors vii
Series preface ix
Preface xi
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PART 1 What is clinical psychology? 1

Chapter 1 What does a clinical psychologist do? 3
Fergal Jones and Charlotte Hartley

Chapter 2 The art and science of psychological practice 19

Nick Lake and Adrian Whittington

Chapter 3 Working in teams: different professions, different models

of care and the role of the clinical psychologist 37
Philippa Casares and Nick Lake

PART 2 Working with children and families 55

Chapter 4 Working with children 57
Mary John

Chapter 5 Working with families 76

Graham Lee and Rosey Singh

PART 3 Working with adults in psychological

difficulty 91
Chapter 6 Working with people with depression 93
Kate Cavanagh and Clara Strauss

Chapter 7 Working with people with anxiety disorders 112

Alesia Moulton-Perkins, Adrian Whittington and
Melissa Chinery
 vi CONTENTS

Chapter 8 Working with people with psychosis 130

Mark Hayward, Sara Meddings and Jo Harris

Chapter 9 Working with people with personality disorders 150

Brian Solts and Renee Harvey

Chapter 10 Working with people with eating disorders 167

Renate Pantke and Neil Joughin
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Chapter 11 Working with people with PTSD and complex trauma 182
Maeve Crowley and Ines Santos

PART 4 Working with people with disabilities

and physical health problems 197
Chapter 12 Working with people with intellectual disabilities 199
Jan Burns

Chapter 13 Working with people with physical health problems 216

Angela Busuttil, Alesia Moulton-Perkins and Monika Tuite

Chapter 14 Working with people with dementia 236

Jane Shepherd, Sally Stapleton and Maureen Jeal

Chapter 15 Working in neuropsychology 254

Angela Reason, Anna Healey and Jan Rich

PART 5 Current professional issues in

clinical psychology 271
Chapter 16 Clinical psychology: past, present, future 273
Adrian Whittington and Nick Lake

Chapter 17 Moving forward into clinical psychology 287

Clara Strauss and Mary John

Index 301
 Contributors

Jan Burns, Professor of Clinical Psychology, Canterbury Christ Church University.

Angela Busuttil, Consultant Clinical Psychologist, Sussex Partnership NHS
Foundation Trust.
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Philippa Casares, Consultant Clinical Psychologist, Sussex Partnership NHS

Foundation Trust.
Kate Cavanagh, Senior Lecturer, University of Sussex.
Melissa Chinery, Expert by Experience, Sussex Partnership NHS Foundation Trust.
Maeve Crowley, Consultant Clinical Psychologist, Sussex Partnership NHS
Foundation Trust.
Jo Harris, Expert by Experience, Sussex Partnership NHS Foundation Trust.
Charlotte Hartley, Clinical Psychologist, formerly at Canterbury Christ Church
University.
Renee Harvey, Consultant Clinical Psychologist, Sussex Partnership NHS
Foundation Trust.
Mark Hayward, Director of Research and Consultant Clinical Psychologist,
University of Sussex.
Anna Healey, Clinical Psychologist, Sussex Partnership NHS Foundation Trust.
Maureen Jeal, Expert by Experience, Sussex Partnership NHS Foundation Trust.
Mary John, Programme Director, Doctorate in Clinical Psychology, University of
Surrey and Consultant Clinical Psychologist, Sussex Partnership NHS Foundation
Trust.
Fergal Jones, Clinical Psychologist, Sussex Partnership NHS Foundation Trust and
Senior Lecturer, Canterbury Christ Church University.
Neil Joughin, Consultant Psychiatrist, Sussex Partnership NHS Foundation Trust.
Nick Lake, Senior Clinical Director and Consultant Clinical Psychologist, Sussex
Partnership NHS Foundation Trust.
Graham Lee, Principal Family and Systemic Psychotherapist, Sussex Partnership NHS
Foundation Trust.
Sara Meddings, Consultant Clinical Psychologist, Sussex Partnership NHS
Foundation Trust.
 viii CONTRIBUTORS

Alesia Moulton-Perkins, Principal Clinical Psychologist and CBT Therapist, Sussex

Partnership NHS Foundation Trust.
Renate Pantke, Consultant Clinical Psychologist, Sussex Partnership NHS
Foundation Trust.
Angela Reason, Principal Clinical Psychologist, Sussex Partnership NHS Foundation
Trust.
Jan Rich, Principal Clinical Psychologist, Sussex Partnership NHS Foundation Trust.
Ines Santos, Senior Clinical Psychologist, Sussex Partnership NHS Foundation
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Trust.
Jane Shepherd, Consultant Clinical Psychologist, Sussex Partnership NHS
Foundation Trust.
Rosey Singh, Clinical Director for Children and Young People’s Services and
Consultant Clinical Psychologist, Sussex Partnership NHS Foundation Trust.
Brian Solts, Complex Care Pathways Director and Consultant Clinical Psychologist,
Sussex Partnership NHS Foundation Trust.
Sally Stapleton, Principal Clinical Psychologist, Sussex Partnership NHS Foundation
Trust.
Clara Strauss, Consultant Clinical Psychologist, Sussex Partnership NHS Foundation
Trust, and Honorary Lecturer, University of Sussex.
Monika Tuite, Principal Clinical Psychologist, Sussex Partnership NHS Foundation
Trust.
Adrian Whittington, Director of Education and Training and Consultant Clinical
Psychologist, Sussex Partnership NHS Foundation Trust.
 Series preface

Psychology is still one of the most popular subjects for study at undergraduate degree
level. As well as providing the student with a range of academic and applied skills that
are valued by a broad range of employers, a psychology degree also serves as the basis
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for subsequent training and a career in professional psychology. A substantial proportion

of students entering a degree programme in psychology do so with a subsequent career
in applied psychology firmly in mind, and as a result the number of applied psychology
courses available at undergraduate level has significantly increased over recent years.
In some cases these courses supplement core academic areas and in others they
provide the student with a flavour of what they might experience as a professional
psychologist.
The original series of Texts in Applied Psychology consisted of six textbooks designed
to provide a comprehensive academic and professional insight into specific areas of
professional psychology. The texts covered the areas of Clinical Psychology, Criminal
and Investigative Psychology, Educational Psychology, Health Psychology, Sports and Exercise
Psychology, and Work and Organizational Psychology, and each text was written and edited
by the foremost professional and academic figures in each of these areas.
These texts were so successful that we are now able to provide you with a second
edition of this series. All texts have been updated with details of recent professional
developments as well as relevant research, and we have responded to the requests of
teachers and reviewers to include new material, and new approaches to this material.
Perhaps most significantly, all texts in the series will now have back-up web resources.
Just as in the first series, each textbook is based on a similar academic formula that
combines a comprehensive review of cutting-edge research and professional knowledge
with accessible teaching and learning features. The books are also structured so that
they may be used as an integrated teaching support for a one-term or one-semester
course in each of their relevant areas of applied psychology. Given the increasing
importance of applying psychological knowledge across a growing range of areas of
practice, we feel this series is timely and comprehensive. We hope you find each book
in the series readable, enlightening, accessible and instructive.

Graham Davey
University of Sussex, Brighton, UK
August 2014
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7KLVSDJHLQWHQWLRQDOO\OHIWEODQN
 Preface

This book sets out to offer a modern introduction to clinical psychology as it is operating
on the ground – delivering clinical interventions, supervision, consultation, leadership,
training and research in changing mental health services. The book places the voice of
the users of these services at its heart, and it is their voices in this text that speak perhaps
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loudest for effective and artful psychological mental health care as a core feature of
services. The content of the book also represents the best of the partnership work
between lead clinicians (at Sussex Partnership NHS Foundation Trust) and clinical
researchers (at the University of Sussex, University of Surrey and Canterbury Christ
Church University), together with people who have experience of using our services.
It is the strength of this three-way partnership, and the richness of the knowledge and
understanding that may be gained from it, that lies at the core of our professional practice,
now and in the future. We hope that many of you who read this book will become
part of this future as practitioners or researchers in clinical psychology.
We know through careful trial evidence and qualitative analysis that psychology
can offer a great deal to improve people’s lives by aiding understanding of difficulties,
delivering psychological therapies, and informing the wider service system with
psychological knowledge. The profession of clinical psychology developed as a way
of deploying competences to apply psychology to health care in the NHS. In the final
decade of the twentieth century it also saw the growth of a multiplicity of professional
groupings working with related aims – multiple varieties of psychological therapists
and psychological well-being practitioners have flourished and developed, supported
through unprecedented levels of public investment in adult and child psychological
services as part of the Improving Access to Psychological Therapies programme in
England, and related programmes across the UK.
All of this leaves us at a pivotal moment – with psychology in the public
consciousness as never before and with ongoing public investment in services that have
dramatically increased access to proven psychological therapies during the past decade.
Some have interpreted the growth of other groups applying psychology in health care
as a threat to the profession of clinical psychology. This fear is ironic because clinical
psychologists have been leading the charge to develop the new services, train the new
staff and deliver evidence-based psychological therapy to more people than ever before.
In fact the public needs clinical psychology more than ever. This is because the science
of psychology does not stand still: developing and delivering the best care requires
those with competences in research, teaching, supervision and consultation to drive the
next phase of change, as well as those able to deliver psychological therapies and inter-
ventions. The users of mental health services are telling us clearly that talking therapies
and psychologically aware services are what they want and need, and research evidence
offers us a clear mandate to expand the availability of psychological interventions. This
will involve developing and researching new ones, as well as applying the ones we
already have.
 xii PREFACE

In addition to the value that clinical psychology offers as a health profession, it is

also an important topic of interest for many undergraduate and graduate students
studying psychology. Because of this, the contents of this text have been designed
around teaching and learning features that may be used as the basis for an intermediate
or advanced-level course that will allow students to learn in both breadth and depth
about clinical psychology. Given the large numbers of undergraduate psychology
students who aspire to a career in applied psychology, we hope that this book will be
a valuable resource in the pursuit of that aim.

Graham Davey
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Nick Lake
Adrian Whittington
June 2014
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1 psychology?
What is clinical
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7KLVSDJHLQWHQWLRQDOO\OHIWEODQN
 1 What does a clinical
psychologist do?
Fergal Jones and Charlotte Hartley
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SUMMARY

Right across the world, as you are reading these words, millions of people are experiencing
profound distress as a result of a wide range of psychological and mental health difficulties.
Rigorous research studies demonstrate that clinical psychologists have the ability to aid
recovery and alleviate suffering in relation to many of these difficulties, and yet their work
is often poorly understood, and may seem mysterious. This chapter begins to demystify
this work by providing detailed examples of the working weeks of two clinical
psychologists. These examples illustrate how clinical psychologists apply psychological
theory and research to understand and alleviate human distress, and introduce the key
concepts of assessment, formulation, treatment and evaluation. The chapter offers an
overview of the different types of specialities that clinical psychologist work in and the
range of work that they do, including providing one-to-one interventions, group-based
interventions, indirect work, consultation and teaching/training, and being involved with
applied research, organisational development and leadership.

INTRODUCTION

Meet Ahmed and Susan.1 Ahmed qualified as a clinical psychologist by completing his
doctorate in clinical psychology two and a half years ago. After working in a number
of temporary posts in the National Health Service (NHS) for his first-year post-
qualification, he successfully applied for a permanent post as a clinical psychologist
in an NHS service that provides health care to adults with intellectual disabilities. In
contrast, Susan qualified eight years prior to Ahmed and worked in a number of varied
posts. She is now a consultant clinical psychologist, the highest clinical grade in the
profession, and is the most senior clinician in an NHS service for adults with common
 4 FERGAL JONES AND CHARLOTTE HARTLEY

mental health problems, such as depression and anxiety. She provides leadership in this
service on all clinical matters.
By reading about Ahmed’s and Susan’s working weeks, you’ll come to see how
the difficulties that people present with in clinical settings can have a psychological
component, how clinical psychologists use psychological theories to help understand
these difficulties, and how they then try to alleviate them by applying psychological
approaches. In some instances the clinical psychologist will work directly with client(s),
while in others the clinical psychologist will support family members, carers or other
staff to use psychological ideas. Clinical psychologists may also be involved in a range
of other activities that draw on their psychological knowledge and skills; a number of
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these will be illustrated. We begin with Ahmed’s week.

‘Patients’, ‘clients’ and ‘service-users’: the implications

of language
The terms ‘client’ and ‘service-user’ are frequently used to refer to the people
FOCUS 1.1

with whom clinical psychologists work. These words are usually preferred to
the more traditional label of ‘patient’. This is because the latter can carry an
implication that the person is a passive recipient of treatment, whereas
psychological approaches usually involve the client adopting an active,
collaborative role, as will become apparent throughout this book.

EXAMPLE WEEK FOR AHMED: CLINICAL PSYCHOLOGIST

IN AN NHS LEARNING DISABILITY SERVICE

People with intellectual disabilities (sometimes also referred to as learning disabilities)

have an intellectual impairment that is apparent from childhood, which means that
they struggle to manage daily living tasks; for example, paying bills, reading letters,
attending hospital appointments. The extent of the challenges they face may depend
both upon the severity of their intellectual impairment and the degree to which their
environment, social networks and living conditions help or hinder them. Ahmed was
particularly drawn to working with this group of people after having a placement in
a community learning disability team during his clinical training. He explained:

‘The disability placement I had during training really changed my perspective. I

hadn’t given much thought before to working with this group of people but it
opened my eyes to how easily people with intellectual disabilities can become
vulnerable and socially excluded. I realised how the work we do as clinical
psychologists has the potential to make real improvements to quality of life.’

You can read more about intellectual disabilities in Chapter 12.

 WHAT DOES A CLINICAL PSYCHOLOGIST DO? 5

Ahmed works four days a week in the NHS learning disabilities service, and spends
the fifth day at home caring for his young daughter while his partner works. Ahmed’s
diary for a typical working week is shown in Table 1.1. The main activities outlined
in his diary are described in more detail later. Sometimes Ahmed’s diary may change
at the last minute, when appointments are cancelled, extra meetings and emergency
appointments are slotted in, people do not turn up to meetings, or unscheduled
telephone calls or emails need to be dealt with urgently.
Let us now consider in more detail what some of the key activities in Ahmed’s diary
involve.
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REFERRAL INFORMATION

Ahmed starts the week by reading some ‘referral information’ about a client, Jacob,
who he has been asked to help. This explains that Jacob has a moderate intellectual
disability and that his carers are concerned because he has started self-harming by
banging his head against a wall. The carers and Jacob find this distressing and the carers
hope that a psychological intervention might help stop this behaviour.
Irrespective of the setting and client group, like Ahmed, a clinical psychologist will
usually receive referral information about the client(s) before she or he meets them.
In some instances this may just be a letter from a psychiatrist or another clinician. In
other cases a client may have been receiving support from the health services for a
number of years and so have several volumes of clinical notes, which the clinical
psychologist may be able to read if they are seeing the client as part of their NHS work.
When reading the referral information clinical psychologists ask themselves whether
it seems likely that psychological approaches could be used to understand and address
the problems described. Often the referral information may not contain enough detail
to make a decision on this, so the psychologist may try to speak with the referrer, if
they are available, and conduct an assessment to investigate further. To this end, Ahmed
speaks to the referrers by telephone and arranges an assessment meeting for Jacob later
in the week.

Assessment
During the assessment, Ahmed meets with Jacob and his carers to gain both of their
perspectives. He attempts to understand more about the problem, including why Jacob
is banging his head. Jacob’s moderate intellectual disability means that he is unable to
explain this and his carers also do not have an explanation. Therefore Ahmed explores
how often the head banging occurs, whether there are any events that occur
immediately prior to each bout of head banging that seem to trigger it, and whether
there were any changes in Jacob’s environment around the time the head banging
episodes first started. He also arranges to return the following week to spend some time
observing at Jacob’s care home, in case that provides further useful information.
As in this example, clinical work usually begins with an assessment. This
information-gathering process can last one or more sessions and takes a variety of forms,
depending upon the client group and the type of intervention the clinical psychologist
plans to use. It is common for clinical psychologists to draw from a range of information
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TABLE 1.1 A typical week from Ahmed’s diary

Monday Tuesday Wednesday Thursday Friday

8.30–9.00 9.00–1.00 9.00–9.30 9.00–9.30 Day at home looking after

Email catch-up. Team ‘away morning’ at Respond to emails and Discuss recent referrals daughter.
the team’s base in large messages. with a colleague and
9.00–9.20
meeting room. Time is decide which clinicians to
Reading referral 9.30–11.30
spent brainstorming ways allocate them to.
information on a new Cognitive assessment
to communicate better
client (Jacob). with a client. 9.30–12.30
and discussing recent
Consultation clinic with
9.20–9.30 changes to management 11.30–12.00
two colleagues and three
Telephone call to Jacob’s structure. Write up clinical notes and
new clients.
carers to get more detailed score cognitive tests.
[Away mornings only
information and to arrange 12.30–1.30
happen occasionally; on 12.00–12.30
an assessment for Write up reports from
other weeks Ahmed’s Lunch.
Thursday. consultation clinic.
morning might be as
12.30–1.00
9.30–12 noon follows]:
Travel
Two individual therapy
9.00–10.30
sessions, including time
Supervision on case
to write up clinical
work.
notes.
10.30–12.30
12.00–12.30
Continuing Professional
Prepare for afternoon
Development (CPD) time
visits by reading clients’
to read up on the research
clinical notes.
evidence around the
12.30–1.00 provision of group work
Drive to a day centre. for people with mild
Eat lunch in car when intellectual disabilities
arrive. who are struggling with
anxiety.
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Monday Tuesday Wednesday Thursday Friday

1.00–1.50 1.00–1.15 1.00–2.30 1.30–2.00

Session with an ongoing Read up on notes for next Meet care staff at new Travel to Jacob’s care
client (Jodi) who is being client and speak to his care home, to discuss a home.
supported through the social worker. new referral and to meet
2.00–3.30
emotional impact of the client (Cleo).
1.15–1.30 Discuss care staff’s
having her child taken
Travel to care home. 2.30–4.00 concerns and meet
into foster care.
Individual session at the Jacob. Complete a
1.30–3.00
1.50–2.00 care home to complete an behavioural assessment
Meet client (Freddie)
Write up notes from assessment of whether and formulation. Start to
who is showing early
session. someone has an make a behavioural
signs of dementia. Carry
intellectual disability using intervention.
2.00–3.00 out the initial part of an
psychological tests.
Client ‘does not attend’. assessment with him 3.30–4.30
Cannot access computer and his key worker. 4.00–5.00 Travel to new community
at this centre so use the Finish early to pick up disability day centre and
3.00–4.30
time to read up on Down’s daughter from nursery. discuss potential
Continue the second part
syndrome and dementia evaluation project to be
of a behavioural
for work tomorrow. carried out jointly with
assessment with another
staff.
3.00–4.00 client.
Meeting with a speech 4.30–5.30
4.30–6.00
and language therapist to Back to base to make sure
Return to base to write
provide consultation and notes are written up and
up notes and score the
advice on a piece of filed away.
psychological measures
clinical work the therapist
used in the assessments.
is doing with someone
who exhibits challenging
behaviour.
4.00–5.15
Return to base. Finish
writing up a cognitive
assessment report from
last week. Check emails
and messages.
 8 FERGAL JONES AND CHARLOTTE HARTLEY

sources, and sometimes they may interview clients, relatives and carers in order to
obtain a range of perspectives. While the majority of information is usually collected
at the beginning of clinical work, new information often comes to light in later sessions
as people’s trust in the clinical psychologist grows.
Sometimes clinical psychologists will use psychological tests as part of an assessment.
For example, on Wednesday Ahmed conducts an assessment to determine whether
someone has an intellectual disability and, if so, the severity of this disability. As part
of this, he administers an IQ test to obtain an estimate of the client’s level of
intellectual functioning and a profile of the client’s cognitive strengths and limitations.
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He uses other psychological measures to gain a sense of the client’s ability to function
in everyday life. As well as determining whether this person has an intellectual
disability and the severity of it, this assessment enables Ahmed to provide feedback to
the client and his support workers regarding his cognitive profile and its implications.
Another key task for the clinical psychologist, which starts during the assessment,
is to develop good working alliances with the people involved. Without this it is more
likely that these people will terminate the work prematurely, and even if they don’t,
that the work will be less effective. See Focus 1.2 for further discussion.

The role of relationship skills

A key part of clinical psychologists’ work is being able to build and maintain
relationships with people, including clients, clients’ relatives and colleagues.
In some cases clinical psychologists will need to build relationships with
clients who have significant difficulties trusting people, as a result of previous
breaches of trust, such as child abuse. Research suggests that one of the
predictors of good outcomes in face-to-face psychological interventions with
clients is the strength of therapeutic relationship that the clinical psychologist
is able to foster with the client.
When thinking about the relationship-building skills that clinical
psychologists need, it can be helpful to start from your own experience.
If you wish, try to recall a time when you felt listened to and understood by
someone. Replay this event in your mind and then write down what that
person did that helped you to feel understood. You may want to think about
what attitude they brought to the discussion, what they said and how they
said it, and what their body language was like. You could repeat this process
for some other occasions during which you felt listened to and understood.
Are there any commonalities in the lists you have drawn up? Now, as a
contrast, if you wish, consider some times when you have not felt
FOCUS 1.2

understood by people to whom you were talking. What was it that these
people were doing differently?
Based on these reflections, what do you think are the key skills and
attitudes a clinical psychologist needs to bring to meetings with people in
order to try to build positive relationships with them?
 WHAT DOES A CLINICAL PSYCHOLOGIST DO? 9

Formulation
A defining aspect of the clinical psychologist’s role is their application of psychological
theory and research findings to understanding the problems with which they are
presented. Clinical psychologists combine the information they have gained from an
assessment with relevant psychological theory and research findings, in order to create
a ‘formulation’. A formulation may be thought of as a psychological understanding of
a client’s problems, and provides a basis on which decisions about helpful interventions
can be made. The process of making connections between assessment information and
psychological theory (which is essential to creating a formulation) is referred to as
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developing ‘theory–practice’ links.

For example, Ahmed draws links between behavioural theory and the information
he has gained during the assessment to develop an initial formulation of Jacob’s head
banging. Part of Ahmed’s formulation is that Jacob tends to bang his head when he is
by himself and seemingly bored. His head banging attracts the attention and care of
staff. Therefore, the head-banging behaviour appears to be communicating Jacob’s wish
for more contact with care staff, and seems to be reinforced by the attention they give
to Jacob when he bangs his head. Furthermore, this formulation suggests a possible
helpful intervention: Jacob could be provided with more human contact and
stimulating things to do when he isn’t head banging, which should reduce the chances
of him becoming bored and feeling lonely.
Sometimes clinical psychologists structure their formulations around predisposing,
precipitating and maintaining factors. In creating a formulation, the clinical psychologist
may be thought of as acting as a scientist-practitioner, since they are applying psychology
theories to clinical practice. Furthermore, like scientists, clinical psychologists will tend
to view their formulations as a series of hypotheses that can be confirmed or
disconfirmed by information that may come to light at a later date. Therefore, the
formulation is frequently modified and refined as the intervention progresses.
There are a variety of different approaches to formulation, including behavioural,
cognitive-behavioural, systemic and psychodynamic, among others. As will be discussed
in more detail in Chapter 2, each of these approaches offers a different way of
understanding clients’ difficulties and a different view on what the intervention should
involve. In brief, behavioural therapy considers people’s behaviours, the function they
serve and the environmental factors that may reinforce them. Cognitive-behavioural
therapy is particularly concerned with the interactions between thoughts (cognitions),
behaviours and emotions. Psychodynamic psychotherapy emphasises the importance
of early relationships and unresolved unconscious conflicts, and systemic therapy focuses
on the systems of which the person is part, such as their family. Therefore, the nature
of the formulation will depend upon the approach adopted by the clinical psychologist.
Some clinical psychologists stick mainly to one approach, while others work in a more
integrative way by drawing upon ideas from different approaches.
While many health and social care professionals draw upon psychological ideas in
their work, the breadth and depth of their training enables clinical psychologists to
draw upon and formulate, using a wide range of psychological theory, in a flexible
manner, across a range of different clinical settings.
 10 FERGAL JONES AND CHARLOTTE HARTLEY

Communication
The ability to communicate clearly with people, including colleagues, clients and carers,
is crucial to being an effective clinical psychologist. For example, in order for his work
to be effective, Ahmed needs to be able to communicate clearly with people with vary-
ing degrees of intellectual disability, care staff and fellow health care professionals, and
in each case pitch what he is saying in an appropriate way that is likely to be under-
stood.
Before communicating, clinical psychologists will usually consider what information
needs to be conveyed, what emotional impact it may have, and what the most effective
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way of conveying it will be. Often clinical psychologists will ask for feedback to gauge
how information is received and understood. Sometimes communicating effectively
with clients or staff can be difficult; for example, when a clinical psychologist is provid-
ing information that a client does not wish to hear or that does not fit with their
worldview.

Intervention
Clinical psychologists are trained to provide a variety of psychological interventions.
The intervention is based on the formulation and depends heavily upon the approach
that a clinical psychologist decides to take. As already discussed, the main classes of
psychological approach are behavioural therapy, cognitive-behavioural therapy, psycho-
dynamic therapy and systemic therapy, and sometimes clinical psychologists choose to work
in an integrative manner by drawing upon a variety of models/approaches. During
the intervention the clinical psychologist pays attention to the quality of their
relationships with the people involved, and to whether changes need to be made to
the formulation in light of new information that becomes available. In some
approaches, the clinical psychologist works collaboratively with the client to shape the
course of the intervention.
Sometimes a clinical psychologist may offer a psychological intervention in one-to-
one sessions with the client. For example, Ahmed meets weekly with Jodi on Monday
afternoons to offer her psychological therapy to help her process and adjust to the loss
of her child, who was taken into foster care, because Jodi had been assessed as being
unable to safely parent him. In other cases they may work indirectly through significant
people in the client’s life; for example, Ahmed encourages Jacob’s carers to provide
him with more human contact and stimulating things to do when he isn’t head
banging, in order to reduce the chances of him becoming bored and feeling lonely
and so starting to head bang. Interventions can also be offered in groups. Group work
can have a number of advantages. For example, clients can find it valuable to meet
other people who are struggling with similar difficulties, since this can help them feel
less alone and offer them a way to provide mutual support. Groups can be a relatively
safe space for clients to build confidence in social situations and explore how they relate
to others. They can also be more cost-effective than individual work. That said, groups
are not suitable for all clients and some clients find it too daunting to attend a group.
Sometimes the clinical psychologist will find it helpful to consider the group as an entity
in its own right, and so they may formulate both their understanding about an
 WHAT DOES A CLINICAL PSYCHOLOGIST DO? 11

individual group member’s difficulties as well as the dynamics or difficulties within

the group as a whole.
Clinical psychologists may also offer interventions to teams and organisations. For
example, during the ‘away morning’ Ahmed helps his team think about intra-team
communication difficulties and this helps stimulate a useful discussion, out of which
emerges an action plan to improve their communication. In other cases it may be that
clinical psychologists take on a more formal consultation role to teams of which they
are not a member (thus offering an outsider perspective and enabling the team or
organisation the space to think differently).
Regardless of its format, an intervention is nearly always preceded by an assessment
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and guided by a formulation that makes connections between the assessment

information and psychological theory. Further examples of interventions are provided
throughout this book.

Evaluation
It is important to evaluate the effectiveness of an intervention, both during its course
and after it is complete. This enables the clinical psychologist to gain a sense of whether
the intervention seems to be having the desired effect. Both quantitative and qualitative
information may be used to evaluate interventions. Quantitative measures assign a
number or numbers to the desired outcomes; for example, to evaluate the intervention
for Jacob’s head banging, Ahmed asks Jacob’s care staff to record how often he bangs
his head each day. A reduction in this daily frequency over time would be consistent
with the intervention being helpful. Quantitative information may also be obtained
from more formal psychological measures and tests; for instance, there are well-
respected questionnaires that measure potential targets for psychological interven-
tions, including depression, anxiety, anger, quality of life, well-being, etc. Sometimes
measures are self-report (i.e. the client completes them) and sometimes they are
completed by people who know the client well; the latter may be more appropriate
where the client has little insight into their difficulties or where their comprehension
skills may make measure completion difficult. As part of his training, Ahmed was taught
how to access and interpret the research literature on psychological tests and
questionnaires in order to select the best available questionnaire for the evaluation task
in hand.
Just as important is qualitative evaluation information. This includes clients’ and
carers’ impressions of whether the intervention seems to be helping and their sense of
what has and has not changed. Usually, clinical psychologists will want to collect both
quantitative and qualitative evaluation information in order to obtain a rounded picture.
However, when interpreting such information, clinical psychologists will be mindful
of factors that may bias it. For example, some clients may want to please their clinical
psychologist and so give overly positive answers, while others may not want the work
to finish and so over-emphasise their problems. If an evaluation suggests that an inter-
vention is not helping, the clinical psychologist, often in conjunction with the client
or carers, will try to understand why this is the case. Once hypotheses have been
developed as to the reasons why the intervention is failing, then the formulation can
be modified and a new way forward planned. This is another example of how clinical
psychologists behave as scientist-practitioners.
 12 FERGAL JONES AND CHARLOTTE HARTLEY

In addition, clinical psychologists may also be involved in evaluating interven-

tions on a wider scale. For example, on Thursday afternoon, Ahmed travels to a new
community disabilities day centre to speak with staff there who want to establish a
programme to evaluate the service they offer. Ahmed helps the staff to crystallise
their evaluation aims and agrees to return the following week, to allow him time
to consult the research literature to see what evaluation tools might be helpful in
this instance.
As an aside, it is perhaps worth adding that the degree of travel that clinical
psychologists undertake as part of their role can vary substantially depending upon the
setting in which they work and how geographically spread (or otherwise) the services
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are into which they provide input.

SUMMARY: STAGE OF CLINICAL WORK

The stages of assessment, formulation, intervention and evaluation are present in the
majority of clinical psychologists’ clinical work. Typically these do not occur as discrete
stages, but rather overlap and blend into each other. Given their importance, they will
be returned to throughout this book.

MULTI-DISCIPLINARY TEAM (MDT) WORKING

Clinical psychologists, like Ahmed, frequently work as members of MDTs. Part of the
rationale for MDTs is that they can provide clients with more holistic care, since they
include workers from a range of disciplines that specialise in different aspects of health
and social care.
Clinical psychologists often provide psychological advice and consultation to MDT
colleagues, to help them develop a psychological understanding of their clinical work.
In addition, clinical psychologists see clients jointly with MDT colleagues when it
seems helpful to do so. For example, fortnightly on Thursdays Ahmed facilitates a
consultation clinic with MDT colleagues, during which he meets with clients together
with colleagues. Team working is discussed in more detail in Chapter 3.

REFLECTIVE PRACTICE

In addition to following the scientist-practitioner model in his clinical work, Ahmed,

like other clinical psychologists, behaves as a reflective-practitioner. For example, during
his work with clients he reflects on the assumptions that he is making, and how his
cultural background and life experiences influenced these assumptions. He also uses
his monthly meetings with his clinical supervisor (a more senior clinical psychologist)
to reflect on his work and assumptions, and to gain his supervisor’s perspective. In
addition, he attends a fortnightly MDT ‘reflective-practice meeting’, which provides
the team with space to reflect together upon clinical work and team issues.
We all have beliefs and perspectives about our self, other people and the world.
These will have been influenced by our cultural background and previous life
experiences. We may be aware of some of the beliefs that we hold, and thus be able
 WHAT DOES A CLINICAL PSYCHOLOGIST DO? 13

to examine their validity. However, it is likely that we have a number of beliefs which
we automatically assume to be true but have not critically examined.
Clinical psychologists reflect on their own beliefs in order to try to reduce the impact
of unexamined assumptions on their work with clients. Supervision meetings with a
more experienced colleague can play an important role in this process because the
psychologist may be blind to some of their own assumptions. Supervision plays a
number of other key roles, including supporting the clinical psychologist’s continuing
professional development and monitoring their work. All practising clinical psychologists
should receive some form of supervision. Some clinical psychologists also choose to
have their own psychological therapy, in order to increase their self-awareness and
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understanding of how they relate to others.

EXAMPLE WEEK FOR SUSAN, CONSULTANT CLINICAL

PSYCHOLOGIST IN MENTAL HEALTH SERVICES

Let us now consider the working week of the more senior clinical psychologist, Susan,
who has reached the highest clinical grading in the profession: ‘consultant clinical
psychologist’. She is the most senior clinical psychologist in an NHS service for adults
with common mental health problems, such as depression and anxiety, and provides
leadership in this service on all clinical matters.
As with Ahmed, during her ‘clinical day’ on Fridays, Susan follows the stages of
assessment, formulation, intervention and evaluation, with communication playing a vital role
throughout. However, given her relative seniority and experience, she tends to see
clients with some of the highest degrees of severity and complexity in the service.
Senior clinical psychologists will often do less ‘hands-on’ clinical work than their
more junior colleagues due to the other demands on their time. However, usually they
will still make the time to do some regular clinical work in order to retain their clinical
skills and to be able to offer clinical supervision and management to others that remains
based in personal clinical competence.

LEADERSHIP

Consultant clinical psychologists in clinical lead roles are typically responsible for
providing clinical leadership to their service and for advising the service director on
clinical matters relating to psychological approaches. For example, as part of her
leadership role, Susan attends the service’s ‘leadership group meeting’, where the
majority of decisions about the service are made or ratified. At the leadership group
and when speaking with the service director, Susan draws upon both her extensive
clinical experience and her knowledge of the research evidence base. For instance,
when the leadership group was reviewing the psychological group-based interventions
the service offered to people struggling with depression, she advised them as to which
interventions had been found to be most effective in research and also about the staff
training and supervision changes that would need to be made to enable these to be
safely and effectively offered by the service.
In leadership roles, consultant clinical psychologists also draw upon their formulation
skills to apply psychological theories of organisational processes to understand the
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TABLE 1.2 A typical week from Susan’s diary

Monday Tuesday Wednesday Thursday Friday

9.00–10.00 9.00–10.00 9.00–10.00 9.00–5.00 9.00–5.00

Peer supervision with Appearance on a local Meeting with a client who Teach on a local clinical Clinical day: assessment
other senior psychologist radio show to help raise has made a complaint psychology training or intervention sessions
in the NHS Trust. public awareness of the about the service to hear programme. with five clients.
effects of anxiety and more about their concerns
10.00–10.30
depression and how and respond to these.
Travel.
people can access local
10.00–11.00
10.30–12.30 services.
Provide supervision to a
Service leadership group 10.00–10.30 psychotherapist in the
meeting. Travel. service.
12.30–1.00 10.30–11.30
11.00–1.00
Meet with team Performance contract
Review the service’s
psychiatrist to agree local review with the local
performance with the
referral pathways between Mental Health
service director and
medics and psychologists. Commissioner.
develop a plan to improve
1.00–1.30 11.30–12.00 this.
Lunch. Travel, using the time to
make several calls to work 1.00–1.30
1.30–3.30 colleagues on both clinical Lunch.
Supervise a trainee clinical and service-related issues. 1.30–2.30
psychologist.
12.00–2.00 Prepare for coroner’s court
3.30–4.00 Review and redraft a appearance.
Write up trainee evaluation service policy on how to
2:30–3.00
form. respond to clients who do
Travel.
not attend sessions. Eat
4.00–5.30
sandwich while doing the 3.00–5.00
Admin, including emails.
work. Appear in coroner’s court
2.00–3.00 to outline the input that
Provide supervision to a the service provided to a
more junior clinical client who subsequently
psychologist. committed suicide.
3.30–5.00 5.00–7.00
Chair the service’s audit Return to base to check
and evaluation group. emails and prepare for
5.00–6.00 teaching tomorrow.
Admin and emails.
 WHAT DOES A CLINICAL PSYCHOLOGIST DO? 15

challenging interpersonal dynamics that sometimes arise within services. For example,
when a restructuring of Susan’s service was planned, many of the staff within the service
started to feel understandably anxious about this, and it seemed that this feeling was
being increased by the anxious interactions among staff. Susan was able to formulate
an understanding of this by drawing on theories of organisational change. On the basis
of this formulation she offered the leadership group advice on helpful ways to work
with this anxiety, including ensuring clear communication with staff, being transparent,
helping staff to feel that their concerns had been heard and helping them to have
ownership in the change process.
As part of their leadership role, consultant clinical psychologists may also be
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involved in developing or reviewing policies and procedures. This is another way in

which they can influence the services that are offered and, as previously, they make
use of their psychological knowledge and experience during this process. For example,
on Tuesday, Susan reviews and redrafts a service policy on how to respond to clients
who stop attending their appointments, drawing on her psychological understanding
of why this may happen.
As with Ahmed, good communication skills are a vital part of Susan’s armoury. For
example, not all her colleagues in the leadership group have the same understanding
of psychological approaches or placed the same value on them as Susan does. Therefore,
she needs to be able to provide clear, succinct and convincing arguments in relation
to them. Overall, Susan attempts to act with integrity, sensitivity and fairness in her
leadership role. This helps her to earn the trust of other staff members within the
team and means that they are more willing to listen to her advice and recom-
mendations.
It is important not to underestimate the powerful effect that competent, trusted
leadership can have on the effective functioning of teams and services, and senior
clinical psychologists can play an influential role in this respect. For completeness, it
is also worth adding that, as part of their leadership role, consultant clinical psychologists
may need to carry out some more emotionally draining but nevertheless important
activities. These may include meeting service users who have made complaints about
the service and responding to these complaints, and attending the coroner’s court when
a user of the service has taken their own life.

SUPERVISION AND CONSULTATION

Like their more junior colleagues, consultant clinical psychologists continue to receive
supervision of their work. Sometimes this may be provided by even more senior and
experienced clinical psychologists. However, more experienced colleagues may not
be available, and so consultant psychologists may instead participate in peer-group
supervision, during which they meet colleagues of a similar level of experience and
seniority, usually from other services within the NHS Trust, to reflect upon and
formulate the challenges they are each facing in their work. Susan participates in a peer-
group supervision once a month on a Monday, with consultant clinical psychologists
from other services.
In addition, consultant clinical psychologists will usually spend some of their time
offering supervision to more junior colleagues. This may range from supervising people
 16 FERGAL JONES AND CHARLOTTE HARTLEY

who are training to become clinical psychologists, to supervising junior clinical

psychologists and other professionals who use psychological approaches (e.g. psycho-
therapists). Susan supervises one trainee clinical psychologist, three psychotherapists and
one junior clinical psychologist. Susan is able to supervise the psychothera-
pists because, following her clinical psychology training, she completed further training
in the form of psychotherapy they use.
Sometimes colleagues from other health professions may not need ongoing
supervision from a clinical psychologist, but may nevertheless wish to receive advice
on the psychological aspects of their work. To this end, clinical psychologists and
consultant clinical psychologists may provide psychological consultation to their
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colleagues. This involves the psychologist helping their colleague to formulate psycho-
logically aspects of a specific piece of clinical work. The aim of consultation is
two-fold: to help the colleague develop a psychological formulation that may aid the
specific piece of clinical work, and to help them develop their ability to think
psychologically about their work more generally. Susan is no exception to this: she
provides consultation to colleagues when they request it and when her diary allows.

TEACHING AND TRAINING

Arguably, fostering psychological ways of thinking among the wider health care
workforce is a key part of the clinical psychologist’s and consultant clinical
psychologist’s role. One way to contribute to this may be through the provision of
training events to health care colleagues. In addition, clinical psychologists may
contribute to the teaching of people training to be clinical psychologists. For example,
on Thursday, Susan visits a nearby university and spends the day facilitating a workshop
on providing consultation and supervision for students on a clinical psychology
training course. (See Chapter 17 for more information about training to be a clinical
psychologist.) Sometimes clinical psychologists may also seek to educate the public
more widely through media work, such as Susan’s appearance on local radio on
Tuesday to increase public awareness of the effects of anxiety and depression and how
people can access local services.

RESEARCH AND SERVICE EVALUATION

As scientist-practitioners, clinical psychologists draw upon psychological theory and

psychologist research. Therefore, the future improvement of the services that clinical
psychologists offer is in a large way dependent upon ensuring that research continues
to occur that helps to improve psychological theory and develop more effective and
efficient psychological interventions. Clinical psychologists’ research training means that
they are in a good position to contribute to this. Some clinical psychologists work in
universities and are heavily involved in such research. Others working in clinical
settings may help research, for example, by facilitating recruitment of participants to
research studies.
Most clinical psychologists working in clinical settings are also involved in audit
and service evaluation; that is, using research methods to examine whether the service
 WHAT DOES A CLINICAL PSYCHOLOGIST DO? 17

is meeting its targets, for example, in terms of waiting times, and evaluating the quality
and effectiveness of the interventions that are offered. Every month on a Tuesday,
Susan chairs the service’s audit and service-evaluation group, because she has the most
research training of all the clinicians in the service. Audit and service evaluation can
provide important information to services about what they are doing well and where
they need to make improvements.

DIFFERENT CLIENT GROUPS, SETTINGS AND PSYCHOLOGICAL

APPROACHES
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Generally, clinical psychologists and consultant clinical psychologists specialise in

working with one, or sometimes two, client groups. This is in part influenced by the
fact that services in the NHS are frequently organised by client group. If a clinical
psychologist wants to work with more than one client group then they will usually
need to have a ‘split post’, which involves being a part-time employee in two different
services. Some of the main client groups are as follows.

• Children with mental health problems or physical problems and their families (see
Chapters 4 and 5).
• Adults with mental health problems (see Chapters 6 to 11).
• Adults with physical health problems (see Chapter 13).
• People with an intellectual disability (see Chapter 12).
• People with brain injuries or progressive degenerative conditions, such as dementia
(see Chapters 14 and 15).
• People with substance misuse difficulties (not covered specifically in this book).

Furthermore, for some client groups there are a range of different settings and sub-
specialities within which clinical psychologists can work. For example, in adult mental
health, clinical psychologists can work in services including, among others, assessment
and treatment services, inpatient units, primary care mental health teams, specialist units
for people with particular difficulties, and forensic services. In addition, clinical
psychologists may choose to specialise in adopting a particular psychological approach
(e.g. cognitive-behavioural, systemic or psychodynamic), or they may choose to work
in an integrative manner by drawing upon a variety of models.

CONCLUSIONS

Clinical psychologists draw upon psychological theory to try to understand the

difficulties their clients are struggling with and then apply psychological approaches to
try to manage or alleviate these difficulties. In general, they act as scientist-practitioners
and reflective-practitioners. Usually, clinical work includes assessment, formulation,
communication, intervention and evaluation. Clinical psychologists are often members
of MDTs and frequently offer consultation and advice to colleagues. Moreover, they
work within a range of different settings and with a variety of different client groups.
Finally, senior clinical psychologists can play influential leadership roles in services.
 18 FERGAL JONES AND CHARLOTTE HARTLEY

KEY CONCEPTS AND TERMS

• Assessment • Multi-disciplinary • Systemic therapy

• Formulation team • Supervision,
• Communication • Behavioural therapy leadership
• Intervention • Cognitive-behavioural • Teaching
• Evaluation therapy • Audit
• Scientist-practitioner • Psychodynamic • Research
• Reflective-practitioner therapy
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LEARNING OUTCOMES

When you have completed this chapter you should be able to:

1 Describe the core elements of the work of a clinical psychologist.

2 Understand how psychological knowledge and research is applied to the
treatment of people in psychological distress.
3 Understand the different types of interventions that clinical psychologists
employ.
4 Understand the role of assessment, formulation, treatment and evaluation.
5 Have an understanding of the range of specialities in which psychologists work.

SAMPLE ESSAY TITLES

• What are the key stages of clinical work and what does each stage comprise?
• Describe the range of activities that clinical psychologists engage in. How does
psychological theory inform how clinical psychologists carry out these activities?
• What are the similarities and differences between the roles of a junior and a senior
clinical psychologist?

NOTE
1 Ahmed and Susan are composites created by drawing on the experiences of a range of
different clinical psychologists and, as such, provide representative examples of the roles
clinical psychologists can take, without violating confidentiality.

FURTHER READING
Beinart, H., Kennedy, P. and Llewelyn, S. (2009). Clinical Psychology in Practice. Oxford: Wiley-
Blackwell.
Cheshire, K. and Pilgrim, D. (2004). A Short Introduction to Clinical Psychology. London: Sage.
Johnstone, L. and Dallos, R. (eds) (2006). Formulation in Psychology and Psychotherapy: Making
Sense of People’s Problems. Abingdon: Routledge.
 2 The art and science
of psychological
practice
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Nick Lake and Adrian Whittington

SUMMARY

We are still at an early stage in developing our understanding of the human mind. This
makes the practice of clinical psychology challenging. There is still so much that we don’t
know and not knowing can be anxiety-provoking for a professional. However, clinical
psychology practice is also enormously rewarding. No two pieces of clinical work are ever
the same, the science is constantly developing, and there is room for real creativity in
what we do. In the end we also help people to get better – and that can feel very rewarding
indeed.
Despite the complexity of our subject, psychological science has made some significant
progress and the profession of clinical psychology grounds itself in this science and plays
a key role in advancing this science. However, clinical psychology practice is also an ‘art’,
and our psychological knowledge often has to be applied creatively to help address the
types of psychological difficulties psychologists face in their everyday practice.
This chapter reviews the principles behind the ‘science’ of clinical psychology, including
the role of the empirically supported treatments, evidence-based practice and practice-based
evidence. It also looks at the ‘art’ of psychological practice; in other words, how a
psychologist applies their psychological knowledge in creative and sometimes unique ways
to help address the complex array of factors that may underpin any one person’s (or couple,
family, group or team’s) particular set of emotional or psychological difficulties. It requires
both rigour to the approach (if we know from the research that this works) and a flexibility
to adapt to the circumstances.
In order to help us navigate this science and art, three overarching frameworks of
psychological practice are introduced: the scientist-practitioner, the reflective-practitioner
and the critical practitioner. The chapter will also give an introduction to the types of
psychological models and theories used in practice, focusing on four of the most influential:
behaviour therapy, cognitive-behavioural therapy, short-term psychodynamic therapy and
systemic therapy.
 20 NICK LAKE AND ADRIAN WHITTINGTON

We will argue that the ‘science’ and ‘art’ of psychological practice should not be seen
as opposing principles. There must be artistry in the application of science, and greater
scientific examination of the ‘art’ of practice, if we are to further develop our capacity to
treat the most complex of human attributes – the mind – and the thoughts, emotions
and behaviour connected to it.

INTRODUCTION TO THE ‘SCIENCE’ AND ‘ART’ OF PRACTICE

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We will begin by introducing three models of psychological practice that are taught
at the start of most clinical psychology professional training programmes and which
help navigate the science and art of clinical practice. These emphasise the roles of
science (the scientist-practitioner), reflection (the reflective-practitioner) and critique
(the critical-practitioner) in the application of psychology into practice. While they
sometimes appear to be in tension with one another, the three frameworks should be
complementary in enabling effective practice.

The scientist-practitioner
The scientist-practitioner model is in essence about applying the rigour and knowledge
obtained from science to the practical problems faced by the practitioner in everyday
life (see Lane and Corrie, 2006). For clinical psychologists, it is the practical application
of the scientific study of psychology to the alleviation of psychological distress that
underpins what we do. The scientist practitioner model is partly about applying what
we know from research evidence obtained from the following sources:

• Randomised controlled trials, which examine how well interventions work in

carefully controlled conditions (the efficacy of the intervention).
• Effectiveness trials, which examine how well interventions work in routine care
environments (the effectiveness of the intervention).
• Case series, which examine possibilities of effects, typically for new interventions,
by examining a number of cases in detail.
• Experimental research, which tests the underpinning principles or psychological
theory behind interventions.

It is also about embedding the scientific principles of hypothesis testing, empirically

grounded psychological theory and careful outcome evaluation in all the work we do.
The scientist-practitioner model has been very important in enabling the develop-
ment of effective psychological practice, with significant advances having been
made through rigorous research since the 1950s. The scientific process has led to the
development of effective psychological treatments for a whole range of difficul-
ties across the lifespan. For example, we know that CBT for depression is effective
for the majority of people who receive it and has more long-lasting effect than anti-
depressant medication (Hollon et al., 2006). Consistently drawing upon evidence-based
practice has helped establish the credibility and value of the profession of clinical
psychology.
 ART AND SCIENCE OF PSYCHOLOGICAL PRACTICE 21

In the UK, the National Institute for Health and Care Excellence (NICE) provides
guidance on what psychological treatments are known to be effective for which
conditions (see Focus 2.1). These recommendations for particular ‘empirically sup-
ported treatments’ (ESTs) are based on the best evidence we have available – usually
outcome research from at least two randomised controlled trials (see Focus 2.2 for
details).
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NICE recommended treatments for different mental health

diagnoses for adults
Depression
Cognitive behaviour-therapy (CBT), interpersonal therapy (IPT) and
behavioural couples therapy. Mindfulness-based cognitive therapy (MBCT) for
people who have suffered repeated episodes of depression.
Where these treatments have been unsuccessful then also choose from:
short-term psychodynamic psychotherapy and counselling.

Bipolar disorder
CBT.

Generalised anxiety, panic, agoraphobia, OCD, social phobia

CBT.

PTSD
CBT and eye movement desensitisation and reprocessing (EMDR).

Eating disorders
Anorexia: family therapy, psychodynamic psychotherapy and cognitive-
analytic therapy (CAT).

Bulimia: CBT and IPT.

Borderline personality disorder

FOCUS 2.1

Extended psychological therapy (model not specified). Consider dialectical

behaviour therapy (DBT) for self-harm.

Schizophrenia
CBT and family interventions.
 22 NICK LAKE AND ADRIAN WHITTINGTON

Randomised controlled trials (RCTs)

RCTs are considered the ‘gold standard’ in outcome research. The key
elements are as follows:

• Clients with the same type of emotional difficulty (e.g. agoraphobia) are
selected from a wider patient group and then divided randomly into
different treatment groups. There must be enough people in each group to
achieve an appropriate effect size; in other words, to ensure that the
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effects are big and significant enough not to have happened by chance.
• One group receives the therapy to be evaluated. Other groups may
receive a different therapy, a different intervention (e.g. a drug), or a
control-based procedure (e.g. active monitoring) which attempts to control
for the general effects of receiving care and attention.
• There is often a waiting list or ‘treatment as usual’ control group to see
whether the patient group may have got better even if they had not
received the intervention.
• An assessment is made of the severity of the person’s condition at
different points during the intervention using a well-established measure.
• There are clear protocols for each of the interventions to ensure that the
interventions are applied consistently.
• The people taking part in the trials are selected, and certain exclusion
criteria applied. These may include the presence of some co-morbid
conditions (e.g. drug or alcohol abuse).
• Some trials are ‘blind’, meaning that people assessing the effects of the
intervention should not be aware of what intervention the person has had.
• Participants are sometimes followed up for some time after the
intervention to determine whether the effects of the intervention are
FOCUS 2.2

maintained.

A powerful technique called ‘meta-analysis’ has been used to draw together

results from across several high-quality RCTs studying the same type of
treatment, in order to make an overall analysis of the efficacy of that
treatment.

Limitations in interpreting the evidence base

While the use of empirically supported treatments should underpin the work of a
clinical psychologist, there are some limitations to the research base which psychologists
need to remain aware of when applying findings to clinical practice. The limitations
are as follows:
 ART AND SCIENCE OF PSYCHOLOGICAL PRACTICE 23

• Most ESTs are based largely on RCTs which themselves have limitations:
o They typically focus on one focal problem, whereas people often suffer with
more than one type of emotional difficulty. Much less research has been done
on determining what types of approaches are best for people with multiple
problems.
o Because RCTs look at the general effects of a particular therapy across a
number of people, they offer less insight into more specific questions about
what type of therapy may best suit a particular individual at a particular point
in time.
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o RCTs include significant attention to fidelity to a specific treatment protocol,

usually based on a manual. Critics have suggested that a manual-based
approach is ‘mechanistic’ and unsuitable for routine care settings, although
others have highlighted that manual-based approaches can and should be
applied flexibly.
• Far more research has been conducted with some therapy models than others, and
this may be partly responsible for the greater recommendation of some therapies
than others in treatment guidance.
• There is strong evidence that the qualities of the individual therapist are as
important, if not more important, than the specific type of intervention given
(Okiishi et al., 2003).
• The tools used to assess ‘outcome’ will vary according to the values and aims of
the approach taken, so some measures (e.g. symptom reduction versus change in
family dynamics) suit some therapeutic interventions better than others.

Given these limitations to the application of empirically supported treatments, it is also

important to introduce the concept of evidence-based practice. This is an approach to
clinical decision making where a psychologist makes a judgement about the best

Choice of therapy
Once we know that a particular intervention has proven effectiveness there
would need to be a good reason for choosing an alternative intervention that
has a weaker evidence base. Good reasons include the following:

• The client making an informed choice to start with a different intervention.

• Target problems that are of greater concern may best be addressed by a
different therapy (different therapies emphasise different target problems
(e.g. emotional/cognitive/behavioural ‘symptoms’ in CBT, repeated
FOCUS 2.3

relationship dynamics in short-term dynamic psychotherapy, or patterns of

‘stuck’ or unhelpful dynamics in a group or family that may be the focus of
treatment in systemic therapy).
• Good-quality previous attempts at an empirically supported treatment have
been unsuccessful.
 24 NICK LAKE AND ADRIAN WHITTINGTON

treatment by drawing on the ‘three-leg stool’ of research evidence (the science), clinical
expertise (the art), and client preferences (Spring, 2007). Where there is no research
evidence at all that directly relates to a clinical issue faced, the skills of the scientist-
practitioner may still be applied by ensuring that we use scientific principles in the
design, implementation and evaluation of the intervention so that we can assess its
impact and effectiveness.

The reflective-practitioner
Expert practitioners can be identified and research trials have suggested that they have
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better results than other therapists no matter what form of therapy they are following
(Okiishi et al., 2003). This further reinforces what we already know: that skilled
psychological practice consists of far more than just simply following prescribed
techniques. What it requires is the ability to bring together potentially conflicting ideas
and difficulties into a defined explanation of problems (the formulation) and then
flexibly to apply psychological knowledge to generate solutions to the issue raised. This
is another component of the ‘art’ of practice. The usual attributes used to define these
skills include wisdom and intuition.
Traditionally, these qualities have been seen as being less open to scientific
understanding or evaluation. However, models have been developed which attempt
to describe how psychologists (and others) may go about developing these ‘clinical
expert’ skills in practice and become more consciously aware of them. Schon (1987)
describes two key elements:

1 Reflection in action: this involves reflecting upon learning within sessions

themselves, connecting with our emotions and what this tells us, and attending
to the theories that guide our thoughts and actions. This process enables us to build
new understandings to inform our actions in the situation as it is unfolding.
2 Reflection on action: reflecting after the event to analyse and review the situation
to gain insight for improved action in the future.

Unfortunately, while a useful framework for highlighting good practice, the lack of
specificity in Schon’s work about exactly what ‘reflection on and in action’ entails
means that the model still fails to open up these qualities to more scientific exploration.
This lack of specificity is a problem for those who emphasise the ‘artistry’ of
psychological practice over the science. Few question the importance of these high-
level skills but if we don’t evaluate the effectiveness of these skills, how can we know
which are the most important, and how can we demonstrate their value in a modern
health care environment that demands evidence?
More recently there has been an attempt to define more clearly the metacompetences
that underpin expert practice within specific therapy models (e.g. Roth and Pilling,
2007). These metacompetences consist of procedural rules for adapting and flexing the
therapy appropriately in different situations and they provide a framework for
navigating a path between the science and art of effective practice. However, to date,
there has still been relatively little research that has examined how these meta-
competences influence outcome.
 ART AND SCIENCE OF PSYCHOLOGICAL PRACTICE 25

Clinical psychology often sells itself on the ability of practitioners to integrate the
best of different therapy models in practice. However, the truth is that there has been
very little research conducted to evaluate the value of an integrative approach
compared to single model therapies. We need to apply more science to the ‘artistry’
of practice.

The critical practitioner

With the development of postmodernism (Lyotard, 1984) and our increasing
understanding of how ‘knowledge’ can often be constructed and maintained by those
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with a vested interest in promoting that type of knowledge, it has become increasingly
important for clinical psychologists also to apply a ‘critical lens’ to their practice in an
attempt to ensure their practice does not unintentionally contribute to continuing social
inequalities and injustice.
Let us take a well-known example. Medicine is sometimes criticised for overly
‘medicalising’ the language of human emotions and distress, applying diagnosis (labels
of illness) to human experiences, thus bringing them under the ‘expertise’ and
‘influence’ of the profession of medicine. A critical practitioner would reflect on how
this use of language may have served to maintain the power and authority of the
medical profession and justify the medical ‘treatment’ of human distress (labelled mental
illness) – historically in large asylums. They might evaluate the strengths and weaknesses
of using this constructed knowledge or language and challenge it where it contributes
to continuing social injustice or poor care.
Applying this critical lens to our understanding of human distress has already led to
some very important changes in our way of conceptualising emotional distress
in mental health and well-being services. We no longer label someone as being ‘a
depressive’ – rather we say that someone has depression. We no longer unquestioningly
apply diagnosis when this isn’t helpful to a person in understanding their difficulties.
There has also been a move away from an ‘illness model’ in mental health towards
‘recovery-orientated practice’ that emphasises personal choice, empowerment and
helping people improve their quality of life rather than focusing only on the treatment
of specific psychiatric symptoms. This has helped to significantly improve the quality
of mental health services and the experiences of people receiving care within them.
It is also important that we question our own practice as psychologists. For
example, a critical practitioner may argue that the dominance of one-to-one therapy
has resulted in psychological distress usually being seen as a result of a ‘fault’ within
the individual (e.g. they are thinking unhelpfully, they keep repeating certain relation-
ship patterns, etc.) – so it is an individual who carries responsibility for it and who
must work on improving their life through therapy. A critical practitioner might argue
that this view overlooks the fact that much human distress is a result of societal problems
that we all have a responsibility to address. For example, is a single, unemployed,
socially isolated, lone parent depressed because she is thinking unhelpfully, or is she
depressed because she never had a real opportunity to learn skills, she lives in extremely
poor housing on a violent estate, and as an Asian woman she experiences racial abuse
within a largely white neighbourhood? In these types of situations a community
psychologist might argue that psychology would have a much greater impact if
 26 NICK LAKE AND ADRIAN WHITTINGTON

resources were targeted at community level to address sources of inequality and

injustice. This may include societal problems and processes such as poverty,
unemployment, poor health, poor education, poor housing, poor community
infrastructure, social stigma and discriminatory attitudes in society. This approach to
psychological work is known in the UK as community psychology (Orford, 2008).

DRAWING UPON THE THREE FRAMEWORKS IN CLINICAL

PRACTICE
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In clinical practice, a psychologist will usually make a decision about treatment

approach with an understanding of the evidence base and a knowledge of what works
for whom (Roth and Fonagy, 2005). However, this decision must be negotiated
with the client, indeed the final decision should always be theirs, and there may be
times when it is appropriate to follow an alternative course (see Focus box 2.3).
Whatever the starting point, the skills of the reflective-practitioner, the perspective of
the critical practitioner and the rigour of the scientist-practitioner are all required to
ensure that:

• we start with a good understanding of what can work and the evidence base for
this;
• we are able to tailor our work appropriately to the unique circumstances facing
each individual client;
• we avoid imposing our own cultural norms or worldview on our client;
• we incorporate our wisdom and intuition in ways that help inform our clinical
practice;
• we create the space to reflect upon what we are doing and learn from that
reflection;
• we evaluate the work we do on an ongoing basis using valid assessment tools and
scientific principles.

This enables the practitioner to draw on the best of the ‘science’ and ‘art’ of practice.

CORE MODELS OF PSYCHOLOGICAL THERAPY IN CLINICAL

PSYCHOLOGY PRACTICE

We will now turn our attention to how the science and artistry of practice are applied
through the use of four core models of psychological therapy. All clinical psychologists
undertake significant training in at least two models of psychological therapy, of which
one must be CBT (BPS, 2013). There are many different models of psychological
therapy, but there are four that have been particularly influential and are likely to be
drawn upon by clinical psychologists. These are behaviour therapy, cognitive-
behavioural therapy, short-term psychodynamic therapy and systemic therapy. We will
illustrate the key concepts and features of each of these models and describe how they
may be applied in clinical work.
 ART AND SCIENCE OF PSYCHOLOGICAL PRACTICE 27

CASE STUDY: ANNA

Anna was a 24-year-old general nurse who was referred by her general practitioner
(GP) suffering from panic disorder, agoraphobia and symptoms of depression.
The panic disorder and agoraphobia had started six months previously when Anna
experienced a panic attack in her local shopping centre. The panic attack had been
very intense and she had been rushed to hospital. Anna initially believed that she
must have been suffering from a heart attack although investigations subsequently
revealed that there was nothing physically wrong with her. She had been due to
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meet her biological mother that day whom she had not seen since she was 6 years
of age. Anna had been very anxious about the meeting. Since the panic attack,
Anna had struggled to go out alone – suffering from severe anxiety whenever she
made an attempt and which would lead her to rush home again. She could manage
short trips – especially by car – if accompanied by her boyfriend whom she had been
with since she was 16 years of age. Anna was also suffering from symptoms of low
mood and depression. She scored 17 on the GAD-7 (a questionnaire measure of
anxiety) and 16 on the PHQ-9 (a questionnaire measure of depression) – scores in
the severe and moderately severe range respectively.
Anna had been taken into foster care when she was 6 years old due to neglect
that she experienced at the hands of her biological mother who was suffering from
the effects of severe alcohol abuse. After various foster placements, Anna was
eventually adopted at the age of 8 and reported developing a close relationship with
both adoptive parents – particularly over time. She said she had also suffered a
period of depression (seeing a psychotherapist in the Child and Adolescent Mental
Health Service) when she was 13. Apart from that, Anna had experienced a happy
childhood with her foster parents, doing reasonably well at school – although she
said she could get anxious at times – and said that she worried more than she felt
she should at the possibility of her boyfriend leaving her. She felt she was overly
dependent on him and wanted to be more self-confident and assertive. She had been
contacted by her biological mother a year previously and had eventually, and
somewhat reluctantly, agreed to the meeting, despite feeling very anxious about
what it could bring up for her.

BEHAVIOUR THERAPY
Behaviour therapy has its roots in academic psychology and draws upon learning theory
– the science of increasing or decreasing certain behaviours through changing what is
paired with or follows these behaviours. The most famous set of experiments that
inform behaviour therapy were by Pavlov (1927), who found that by pairing an initially
neutral stimulus (a bell) with a naturally occurring unconditioned stimulus (e.g. the
smell of food) that produces salivation (the unconditioned response), the bell (becoming
a conditioned stimulus) could eventually on its own produce a conditioned response
(salivation) even in the absence of food. This process has been called classical conditioning.
The second important process is operant conditioning (Thorndike, 1911). This is based
on the principle that behaviour can be increased and decreased depending on the
 28 NICK LAKE AND ADRIAN WHITTINGTON

consequences associated with the behaviour. By manipulating the consequences the

behaviour can be changed. Specific processes include the following:

• positive reinforcement (behaviour increasing when paired with a positive

consequence);
• negative reinforcement (behaviour increasing when it allows avoidance of a
negative event);
• punishment (behaviour reducing as a result of negative consequences).

The behavioural view of psychological distress

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The principles of operant and classical conditioning were used by behavioural

psychologists to explain what causes and maintains a wide variety of emotional
difficulties. The principles of behaviour therapy are that:

• All human behaviour is determined by classical and operant conditioning.

• Establishment of maladaptive anxiety is through the process of classical condi-
tioning, maintenance through the process of operant conditioning.
• Mental health symptoms are discrete pieces of behaviour which have arisen
through faulty or unhelpful learning.
• Maladaptive behaviour can be altered by means of unlearning.
• The focus of therapy isn’t on the past – it is on how the behaviour can be changed
in the here and now through the application of behavioural interventions.

Behaviour therapy draws upon its understanding of what causes and maintains
symptoms, and uses a range of techniques including exposure therapy (supporting
someone to stay in the feared situation to enable them to learn that it isn’t threatening),
stress inoculation training (including relaxation training and mental rehearsal),
behavioural activation (helping people who are depressed to gradually increase activities
which can be rewarding and which break the behavioural cycles that maintain
depression), operant conditioning (e.g. giving rewards, providing praise for children)
and structured problem solving.
There is a strong body of empirical support for the effectiveness of behaviour therapy
(Spiegler and Guevremont, 2009).

A behavioural view of Anna’s difficulties

Anna was initially referred to a clinical psychologist, Paul, who took a largely
behavioural approach to his work. Paul was interested in Anna’s behaviour – her
avoidance of going out alone – and how this was linked to the maintenance of her
panic and fear. He also paid attention to the fact that Anna now avoided all activities
she had previously enjoyed and began to explore with her the role this played in
maintaining her depression.
Towards the end of the first session, Paul developed a behavioural formulation
collaboratively with Anna. Anna’s agoraphobia had originally been triggered on the
day she was due to meet her biological mother. The initially neutral stimulus (being
away from home in a crowded space) became associated with intense anxiety (originally
the intense anxiety she felt about the upcoming meeting with her mother) through
 ART AND SCIENCE OF PSYCHOLOGICAL PRACTICE 29

the process of classical conditioning (albeit just through a single event). Being away
from home alone then became associated with intense fear. The association was
maintained by the fact that Anna subsequently avoided going out so that the association
between fear and going out failed to be desensitised. Instead, the association was
negatively reinforced by the avoidance behaviour (i.e. Anna believed that the only
reason she didn’t experience intense fear was because she was successfully avoiding
going out alone).
This formulation led to Paul and Anna agreeing to take forward a course of
behaviour therapy, which would initially aim to address the agoraphobic avoidance
through exposure work. There is a good evidence base for this approach. The therapy
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would involve helping Anna take a graded approach to gradually increasing the amount
of time she spent outside the home on her own, managing the anxiety in the situation
through applying relaxation strategies, and by making sure her anxiety had reduced
significantly before returning home.
Anna engaged well in therapy and over time the treatment helped her reduce the
association between being away from home and fear and to increasingly go out further
and further away from home alone. Anna was discharged after eight sessions of therapy.

COGNITIVE-BEHAVIOURAL THERAPY

Behavioural therapy is often criticised for the fact that it largely focuses on overt,
measurable behaviour and is generally less interested in internal subjective experiences,
such as cognition or emotion. Cognitive therapy in contrast stems from the viewpoint
that our subjective thoughts or perceptions about something have a direct impact upon
our behavioural or emotional state (Beck et al., 1979). According to the cognitive model:

• Psychological disturbance comes from unhelpful ways of viewing the self, the
world and the future.
• Emotions and behaviour are shaped directly by cognitive processes.
• Cognitive processes are accessible to consciousness in the form of thoughts and
images, and so the person has the potential to change them.
• The meaning we give to a situation will be determined by our beliefs or ‘schemas’
that we bring to it. These are also accessible and may be altered.
• By learning to identify unhelpful beliefs and schemas, and by reviewing and testing
out alternative beliefs, it is possible to change the unhelpful beliefs that are serving
to maintain or trigger someone’s symptoms.

There is considerable evidence for the effectiveness of cognitive and cognitive-

behavioural treatment approaches (Stewart and Chambless, 2009; NICE, 2009, 2011).

A cognitive-behavioural approach to Anna’s difficulties

Anna was re-referred to the service six months later as her anxiety had returned. Paul
had left for another job, so Clare (another clinical psychologist) began seeing her. Clare
used a cognitive-behavioural formulation to generate a further understanding of
Anna’s difficulties. Together, they began to identify a vicious cycle that was serving
to sustain Anna’s difficulties with panic attacks and agoraphobia. This vicious cycle
 30 NICK LAKE AND ADRIAN WHITTINGTON

for Anna consisted of the physical sensations of anxiety that she had come to experience
in outside spaces, which she was misinterpreting, thinking they might be signs of an
impending heart attack. Understandably this led to the emotion of fear. In response to
this meaning she was ascribing to the sensations, Anna’s behaviour in these situations
consisted of avoiding or escaping from these situations as soon as the sensations
occurred.
In the background, the formulation also began to identify more long-standing beliefs
of relevance to Anna’s difficulties. For Anna, this included a set of beliefs based in her
early experience that had been activated by her current situation. Her early experiences
of struggling to bond with her biological mother had left her with a deep vulnerability
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and a set of core beliefs around being ‘unlovable, inadequate and helpless’. While her
later positive protective experiences with her adoptive parents had served to foster an
alternative set of more positive core beliefs, getting back in touch with her biological
mother had served to reactivate these negative core beliefs.
Clare began to work with Anna by helping her to break the vicious cycle of panic,
by testing out whether her misinterpretations of physical sensations of anxiety as a sign
of imminent physical disaster were actually true. This included providing information
about the body’s normal response to anxiety (the ‘fight-flight response’ caused by a
surge in adrenaline), and testing out what happens if these sensations are allowed to
run their course without intervening. This enabled Anna to discover for herself that
the sensations were not actually signs of a heart attack but benign and normal responses
to stress. Knowing this in turn reduced the intensity of the fear response, and therefore
the sensations. These tests of what happens to the sensations are known as ‘behavioural
experiments’.
Towards the end of the work, Clare also began to help Anna re-examine her
troublesome core beliefs to see if they were really useful and relevant to her life now.
This enabled Anna to develop a capacity to hold on firmly to the more positive set
of beliefs she had about herself that had been active before her biological mother got
back in contact.

PSYCHODYNAMIC THERAPY

Psychodynamic therapy has its roots in the medical profession which helped to
provide it with legitimacy. It was established in a white European middle-class social
context and was traditionally applied to ‘neurotic problems’. However, more recently
it has been extended to provide treatments for more severe forms of emotional distress
including psychosis.
There are many forms of delivery of psychodynamic therapy including several short-
term dynamic psychotherapies such as time-limited dynamic psychotherapy (Levenson,
1995), short-term dynamic psychotherapy (Malan, 1979) and brief dynamic
interpersonal therapy (Lemma et al., 2011). Most short-term approaches focus on the
ways in which emotional and relationship dynamics that are set up early in life come
to be replayed in later life in ways which may be unhelpful for the person and in ways
that give rise to psychological symptoms. The core principles behind these models are
that early life experiences – usually with early caregivers – give rise to internalised
models and behaviours about what it takes to remain connected emotionally to that
 ART AND SCIENCE OF PSYCHOLOGICAL PRACTICE 31

caregiver. While these models and behaviours may have been adaptive in childhood,
enabling the child to survive psychologically and maintain as close a connection as
possible to the caregiver, in adulthood these internalised models of relationships can
lead the person into repeated relationship patterns which are unhelpful and distressing.
They may also give rise to psychological symptoms.
Short-term psychodynamic therapy does not focus on the reduction of symptoms
per se (although there is an expectation that these will be alleviated by treatment) but
instead focuses on changing these ingrained patterns of interpersonal relating (or
personality style). Therapy aims to achieve this by bringing these patterns into
consciousness, by focusing on particular relationship themes or issues, by giving clients
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new experiences of relationships and by enabling them to understand and integrate

these experiences into their conscious awareness (developing new understandings).
Helping the client to recognise and work through the repeated dynamics (emotions
and behaviour) from the past that are being repeated in the client’s experience of the
therapy relationship as well as in other current relationships are central to the work.

A short-term psychodynamic perspective on Anna’s difficulties

Clare primarily took a cognitive-behavioural approach in her one-to-one therapy
work. However, she had also received further training in short-term psychodynamic
therapy, which she would sometimes use when CBT hadn’t been successful previously
for a client and where the origins of a person’s difficulties had a strong interpersonal
focus (as recommended by NICE depression guidance: NICE, 2009). While Anna
avoided changing treatment approach in the middle of CBT, particularly when this
was going well, she did at times find it useful to draw upon other models of therapy
to help inform her work, although remaining centred in a CBT-based framework.
After the fifth session, Clare became increasingly aware that Anna had become more
sensitive about perceived rejection from Clare. Anna also began to swing between
being quite off hand and dismissive of therapy and then subsequently being very
apologetic and extremely compliant, voicing her anxiety about not being a good
enough client with fears that the therapist might stop working with her because she
was failing to make enough progress. Clare also recognised that she was, at times,
feeling increasingly worthless as a therapist despite the progress they were making and
that she had an urge to try to finish therapy sooner rather than later.
Clare gave herself time to reflect on what she was feeling and brought this to
supervision. This helped her to develop an understanding of how Anna’s early
experiences of her relationship with her mother might be being replayed in the therapy
relationship (because this was Anna’s internal model of all close relationships) and that
Anna’s feelings about her mother might be being ‘transferred’ on to Clare (this is
known as the transference in dynamic therapy). She also reflected on the fact that Anna’s
early ways of coping with the anxiety of being rejected by her mother (moving
between a rejection of her mother when she was drinking to the attempt to create a
close, dependent relationship at other times – both ways of trying to defend against the
anxiety of being rejected herself) was also replaying itself in Anna’s relationship with
her. Her supervisor helped Clare to reflect on the fact that her own feelings (an urge
to be rejecting) might also be a result of these dynamics. Clare made sure that she
noticed these feelings but didn’t act on them directly.
 32 NICK LAKE AND ADRIAN WHITTINGTON

Clare felt that it was important to maintain a CBT approach to treatment and did
not move to a short-term psychodynamic approach. However, using the themes of
rejection of others/dependency on others, the therapist used what was being played
out in the therapy relationship (transference) to help Anna become conscious of the
patterns she repeated in relationships and to test out a new way of relating through
the therapy relationship – one where she could be more assertive without feeling
rejected or abandoned by the psychologist. The psychologist also helped Anna to be
more conscious of the relationship dynamics she was repeating with other important
people in her life, particularly her boyfriend, and how she might work on changing
these dynamics.
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Anna was able to develop an understanding about how this way of relating kept
her in an unassertive position and reinforced her sense of neediness and dependency.
Through the therapeutic relationship initially, Anna discovered a new way of relating
which gradually generalised to her other relationships. She began to feel more
confident, more assertive and less distressed.

SYSTEMIC THERAPY

There are a variety of models of systemic therapy including the structural systems
approach, the Milan model, strategic systemic therapy and post-constructionist therapies
including narrative therapy (see Dallos and Draper, 2010).
Although there are key differences between these approaches, the common element
to all systemically orientated therapies is that they tend not to focus on individual
problems but rather on the role of the system (e.g. couple, family, group or
organisation) in which the individual problem is located. The focus of the treatment
isn’t on the individual themselves, or directly on their symptoms, but rather on the
‘stuckness’ in the system (usually the family) that is giving rise to these symptoms. The
assumption is that you must work with the stuck system to promote change.

A systemic perspective on Anna’s difficulties

After the twelfth session, Anna began to talk about the way in which her adoptive
parents had reacted when she had told them about the contact made by her biological
mother. They had become very cross with Anna for even thinking about agreeing to
see her biological mother and Anna had felt extremely anxious about either letting
them down or letting her mother down. At a deeper level, she feared that her
worthlessness might be reinforced in the minds of either her biological mother or her
adoptive parents, depending on whether she decided to see her biological mother or
not. This tension had played a significant part in her original anxiety. Becoming
agoraphobic had enabled Anna to avoid making a decision on this and she had told
her biological mother that she was too unwell to meet her – at least for the time being.
From a systemic perspective, the psychologist wondered whether Anna’s difficulties
might be being maintained by the fact that her emotional difficulties were helping to
resolve a relationship dilemma in the family system in that it enabled the family to
avoid the possibility of rejection being enacted between Anna, her biological mother
or her adoptive parents. If this were the case, it could be making it difficult for Anna
 ART AND SCIENCE OF PSYCHOLOGICAL PRACTICE 33

to make progress in treatment. The psychologist decided to gently explore this

possibility with Anna and to use this hypothesis as a way of opening up a conversation
about how Anna might address the tensions with both her adoptive family and
biological mother in a different way. Anna responded very positively to this exploration
and she decided that she would try to share her own views and concerns with her
adoptive parents. They met, and her adoptive parents reacted very warmly to Anna
when she talked about the dilemma she was in. They said that they would be okay
with her meeting her biological mother. Soon after, Anna began to make much more
significant steps forward in her CBT treatment.
Anna was discharged after 20 sessions of therapy. At the end of therapy, depression
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and anxiety had both fallen significantly to the ‘not depressed’ and ‘mild anxiety’ ranges
on questionnaire measures (PHQ-9 = 3; GAD-7 = 5). Anna and Clare produced a
written summary ‘blueprint’ together of what had been learned in therapy and
identified ways of recognising and tackling any future difficulties. Anna was very
pleased with the progress she had made and the ending of therapy went well.

REFLECTING ON THE THERAPY

Clare was aware that she had to carefully monitor why she was moving away at times
from the CBT treatment model for panic and agoraphobia. She did not take a short-
term dynamic or systemic approach – remaining largely cognitive in focus – but she
did use her psychodynamic and systemic understanding of the work to flex the way
she applied CBT. She based this work on a clearly developed psychological formulation
that she had shared with Anna, and she brought the case regularly to supervision. Her
work could be described as an integrative approach based within a largely CBT
framework. She brought her psychodynamic understanding of the work to help her
address and work through tensions and difficulties developed within the therapy
relationship that might have interfered with therapy had they not been explored and
made conscious. This helped Anna not only in therapy but also in recognising patterns
of relating that had become generally unhelpful in her life. A systemic perspective,
shared with Anna, helped Anna begin to have important conversations with her
adoptive parents that she had previously been avoiding and which may have been
contributing to her feelings of stuckness.

CONCLUSION

We hope we have demonstrated the key role of both science and artistry in the practice
of clinical psychology. As our profession continues to grow and develop we will need
to continue to use ‘artistry’ in our application of the ‘science’, balancing the need for
rigour in the skilled application of the treatment with the need to remain sufficiently
flexible and creative to ensure that we meet the specific needs of each individual client.
However, it will be just as important to undertake a greater scientific examination of
the ‘art’ of practice, including developing a greater understanding of the therapist factors
(e.g. empathy, genuineness and positive regard) that seem to play such an important
role in outcome. By combining the art and science of practice in this way we will be
 34 NICK LAKE AND ADRIAN WHITTINGTON

able to generate a more sophisticated understanding of human distress and an ever-

growing knowledge of what we can do to alleviate it.

KEY CONCEPTS AND TERMS

• Clinical psychology: • Scientist-practitioner • Cognitive-behavioural

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art and science • Reflective- therapy

• Psychological practice practitioner • Short-term
• Psychological therapy • Critical practitioner psychodynamic
• Empirically supported • Community therapy
treatment psychology • Systemic/family
• Evidenced-based • National Institute of therapy
practice Health and Care
• Randomised Excellence
controlled trial • Behaviour therapy

LEARNING OUTCOMES

By the end of the chapter the reader should have:

• An understanding of the necessity of both science and artistry in the delivery of

psychological treatment.
• A critical appreciation of three frameworks of practice that inform the work of
clinical psychologists:

o the scientist-practitioner model

o the reflective-practitioner model
o the critical practitioner model.

• An awareness of the core principles underpinning four of the most influential

models of psychological practice:

o behavioural therapy
o cognitive-behavioural therapy
o psychodynamic therapy
o systemic therapy.

• Through the use of a case study, an understanding of how these different

psychological models may be used to help alleviate psychological distress.
 ART AND SCIENCE OF PSYCHOLOGICAL PRACTICE 35

SAMPLE ESSAY TITLES

• What are the key components of the ‘science’ of clinical psychology practice?
• Is clinical psychology practice an art, a science, or both?
• What role does evidenced-based practice play in psychological treatment?
• What are the common psychological therapy models applied in clinical psychology
practice and what evidence base is there for these models?
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REFERENCES

Beck, A., Rush, A., Shaw, B. and Emory, G. (1979). Cognitive Therapy of Depression. New York:
Guilford Press.
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 36 NICK LAKE AND ADRIAN WHITTINGTON

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 3 Working in teams
Different professions, different
models of care and the role of
the clinical psychologist
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Philippa Casares and Nick Lake

SUMMARY

In health care, and in the NHS in particular, it is rare for clinical psychologists to work
alone. They usually work as part of a multi-disciplinary team, i.e. a group of individuals
with different training and skills who come together to offer the best care they can to an
individual client. The rationale for multi-disciplinary work is simple. No one professional
can hold expertise in the assessment and treatment of the wide range of biological (e.g.
low serotonin), psychological (e.g. poor attachment history) and social (e.g. unemployment)
factors that result in mental illness. By drawing on the knowledge of different professionals
we can ensure that the client receives the right treatment based on a comprehensive
understanding of their difficulties.
Because team working is so central to the work of an NHS clinical psychologist, this
chapter focuses explicitly on the nature of team work in mental health and what enables
these teams to be effective. We will review the roles of the different professionals and
the models of care they traditionally draw upon in their practice. We focus in particular
on the roles clinical psychologists play in these teams that take them beyond their direct
clinical work with clients. This includes staff support, training and supervision, team
development, team formulation, the development of reflective practice sessions and clinical
leadership.

OVERVIEW

The effectiveness of multi-disciplinary working in mental health stems from the rich
mix of professionals within these teams, each with different backgrounds and training,
and the different perspectives they bring to our ability to understand and offer
 38 PHILIPPA CASARES AND NICK LAKE

treatment to people in distress. Unfortunately, bringing a group of different

professionals together doesn’t necessarily mean that they will work as a functional team.
Team dynamics, competition between individuals, professional rivalries, different
approaches to understanding and treating emotional distress, and a struggle to
understand and value the different perspectives which different professionals can bring
can all result in teams that struggle to make creative use of the different viewpoints
and skills of the people within it.
So what does help teams to work effectively? We know that role clarity – people
knowing and respecting their roles and other people’s roles in the team – is one
important element (BPS, 2007). The chapter will therefore begin by giving the reader
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an overview of the work done by the different professionals who work within a mental
health team.
We also know that clear purposes and goals (including a common philosophy and
culture of care) are also important for teams. The chapter will therefore explore some
of the key differences in the ‘knowledge’ brought by these different professional groups
to the understanding of human distress, focusing in particular on the role of the medical
model (and diagnosis), the psychological model (including formulation) and the
biopsychosocial model which attempts to integrate each of these perspectives with an
understanding of how the social context impacts upon mental health. We will also
review the very significant impact of the ‘recovery model’ (increasingly now referred
to as recovery-orientated practice), which emphasises human growth and the
maximisation of human potential over a specific focus on the alleviation of symptoms.
We will review the potential strengths of each perspective as well as illustrate, through
a case study, how these are brought together, often very creatively, to help clients in
our care.
The final part of this chapter will focus in more depth on the particular roles that
clinical psychologists have within these multi-disciplinary teams.

INTRODUCTION TO PROFESSIONAL ROLES WITHIN MENTAL

HEALTH MULTI-DISCIPLINARY TEAMS

A number of different professions work collaboratively together in mental health multi-

disciplinary teams. The success of the team will depend on the extent to which the
team can effectively harness the different skills and perspective which each profession
brings. It is therefore vital that every member of the team has a detailed and compre-
hensive understanding of the knowledge and skills of each professional group. An
overview of these roles is provided here in Focus 3.1.

Service managers
In NHS Mental Health Services, service managers usually come from a nursing, social
work or occupational therapy background (although some people enter management
without a core clinical training through NHS management schemes) and have
progressed through their careers to management. They provide leadership to teams,
ensuring safe practice of the team as a whole, and coordinating the work of the
professionals within it. They also work closely with more senior managers to ensure
 WORKING IN TEAMS 39

Professions and roles in mental health teams

• Managers
• Psychiatrists (doctors)
• Psychologists (usually clinical or counselling psychologists)
• Mental health nurses
• Occupational therapists
• Social workers
• Psychological therapists
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• Speech therapists (in learning disabilities teams)

FOCUS 3.1

• Health care or nursing assistants

• Support workers
• Peer recovery workers (people who draw on their experiences of using
mental health services to support others)
• Administrators.

that the service is developing in line with NHS Trust policy, is meeting NHS Trust
targets, and is maintaining appropriate standards of care.

Psychiatrists
Psychiatrists are medically trained doctors who have specialised in the field of
mental health. They will have trained for a minimum of nine years with a three-year
undergraduate medical degree followed by a three-year basic specialist training and
three-year higher specialist training. They tend to offer specialist mental health
assessments, diagnoses (see below), and oversee and monitor the prescription of
psychiatric drug treatments. Some psychiatrists also undergo additional training
in psychotherapy but due to the demands on their time they will more often refer
to psychology or other staff for specific psychotherapeutic treatments. They are
usually one of the most senior clinicians within the team and they provide clinical
leadership to these teams, helping to coordinate and oversee the work of other
professionals.

Clinical psychologists, counselling psychologists and

psychological therapists
Clinical and counselling psychologists have usually trained for a minimum of seven
years, with an undergraduate psychology degree followed by work experience and then
a three-year in-service training, usually at doctorate level. Psychotherapy training now
takes place over a minimum of four years and often requires degree-level qualifications
before commencement. Together, these professionals tend to offer the mainstay of
psychotherapy treatments within community mental health teams. They also provide
support and supervision to other staff members offering psychotherapy or psycho-
therapeutically informed treatments.
 40 PHILIPPA CASARES AND NICK LAKE

Clinical and counselling psychologists also tend to be senior members of the

clinical team and many provide a clinical leadership role within these teams. Clinical
directors (clinicians who occupy a senior clinical leadership role in an organisation)
tend to be from either a psychiatric or clinical/counselling psychology background.

Community mental health nurses (CMHNs)

CMHNs have usually trained for three to four years for a nursing diploma or degree
to provide general nursing care including mental health assessments, supportive
therapeutic relationships and psycho-educational treatments (e.g. explaining what it
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means to experience anxiety and what might help), as well as to advise on and
administer medical interventions (such as regular ‘depot’ injections of psychiatric
medication that avoids someone having to remember to take their medication daily).
Some CMHNs do further training in psychotherapeutic interventions including
cognitive-behaviour therapy (CBT) or family interventions training. Some now also
prescribe a limited range of medications.
Because of their broad-based training, CMHNs commonly take on the role of care
coordinators within mental health teams, coordinating the care of the various different
professionals and organisations involved in providing services to people with particularly
complex and high-risk needs (e.g. someone who is homeless, suffers from
schizophrenia, abuses alcohol, and who is vulnerable to abuse and exploitation by
others). They may also play a particular role in helping people to manage periods of
crises where a person may be particularly vulnerable to self-harm or suicide.

Occupational therapists (OTs)

Most occupational therapists have completed a three-year degree in OT. If they
specialise in mental health their role tends to focus on skills development and
supporting service users’ recovery by helping them to develop meaningful activities
of daily living which may include returning to work or learning to live independently.
OTs often offer psycho-educational groups to support recovery. Some OTs will also
have further training in psychological or psychotherapeutic interventions such as
behavioural activation and graded exposure, which are recognised therapeutic
approaches to depression and anxiety.

Social workers
Most social workers are trained to degree or Masters level in specialist social work
courses. The main focus of the work is on the social care needs of service-users. This
means that social workers will be involved in supporting housing needs and helping
service-users to manage their benefits, know their rights, and they will protect them
appropriately when they are vulnerable. Social workers often get involved in supporting
carers of those with mental health problems and many of them are further trained as
approved mental health professionals (AMHPs), which means that they can carry out
specialist Mental Health Act assessments when a service-user may need compulsory
treatment (sectioned). Like many of the other mental health professionals, some social
workers will also have undergone further training in specialist psychotherapies.
 WORKING IN TEAMS 41

Nursing assistants, support workers and peer support

workers
Nursing assistants and support workers do not hold a core professional training,
although some are looking for experience of working with people with mental health
problems prior to going on to further professional training. Peer support workers also
don’t normally have a professional training but they do have direct experience of their
own mental health problems and recovery which they will then use to support and
help service-users manage theirs. Both tend to use practical and supportive methods
to encourage service-users to develop and maintain meaningful and satisfying lives.
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This may include taking service-users out to a support group or other activity, or
helping them to learn the skills of independent living.

Administrative staff
Secretarial staff continue to support the work of the team by organising appointments,
sending out letters and coordinating much of the day-to-day running of the office base.
They can be a great support to the professionals and, as the front door to the service,
they set a key first impression for people entering our services.

DIFFERENT PERSPECTIVES BROUGHT TO THE UNDERSTANDING

OF HUMAN DISTRESS

Mental health is perhaps unique in the fact that the different training received by the
different professions means that different professional groups can take different
perspectives in how they come to view and understand emotional distress. When a
team works well together, these different perspectives enable a rich understanding to
be developed of the various factors that contribute to any one person’s difficulties.
However, these differences can also lead to tension and rivalry when individuals and
teams struggle to integrate and harness these differences. Some of these ‘perspectives’
are reviewed here.

The medical model: diagnosis

At its simplest, the medical model views many forms of human distress as conditions
or illnesses. These ‘illnesses’ tend to be ‘diagnosed’ when a person exhibits a certain
cluster of emotional and behavioural characteristics that have become associated with
a particular condition. The conditions tend to be linked to particular biological, genetic
or neurological difficulties. It is important not to confuse the ‘medical model’ with
general psychiatric assessment, as most psychiatrists nowadays take a much broader
approach to the understanding of mental illness.
Diagnosis is used within mental health services to identify and ‘label’ the types of
problems that a service-user is struggling with and to help inform what might therefore
be the most appropriate treatment. To date, mental health services have tended to be
configured around diagnoses. Psychiatric diagnosis also tends to be used for the majority
of research trials in mental health so that most of our evidence base for medical and
 42 PHILIPPA CASARES AND NICK LAKE

psychological treatments is related to psychiatric diagnosis. There are currently two

widely established systems for classifying mental disorders: The ICD-10 (International
Classification of Diseases, WHO, 1992), which tends to be used in the UK, and the
more recently published DSM V (Diagnostic and Statistical Manual of Mental Dis-
orders, APA, 2013), which tends to be used more in America.
There is no doubt that psychiatric diagnosis can be very reassuring for some service-
users who feel safer having a label for what they are experiencing and to have some
idea of what to expect given the diagnosis they have. They can also feel empowered
by knowing what treatments are recommended by NICE (National Institute for Care
and Health Excellence, the NHS body that makes recommendations about particular
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treatments) for their particular diagnosis. Diagnosis is also a convenient way of labelling
certain collections of symptoms and helps services to organise themselves around these
labels. However, there is a considerable amount of controversy that still surrounds the
activity of labelling or diagnosing human distress as discrete forms of ‘mental illness’,
with many arguing that this over-medicalises their condition. The argument is further
strengthened by the fact that many diagnoses have little reliability or validity in the
way they are applied, many have little explanatory power, and many (e.g. schizo-
phrenia) collect together such a broad range of symptoms and human experiences that
the label itself tells us very little.
Some service-users clearly experience diagnostic ‘labelling’ as demeaning and
stigmatising, and do not feel that the label helps them to make sense of their symptoms
or understand why they are struggling in the way that they are. Clinical psychologists
and other professionals must remain very sensitive to these issues. This is particularly
the case for possible diagnoses of ‘personality disorders’.
The controversy around diagnosis has heightened over the past year with the
publication of DSM V and the subsequent publication by the DCP (Division of Clinical
Psychology, the professional body that regulates clinical psychology) of its controversial
‘Position statement on the classification of behaviour and experience in relation to
functional psychiatric diagnosis: Time for a paradigm shift’ (DCP, 2013). The DCP
is looking for a more holistic, less categorical approach to understanding mental health
problems to allow for a more balanced view of the biological, psychological and social
determinants of emotional distress. One of the ways forward, proposed by the DCP,
is a greater emphasis on formulation.

Formulation
A formulation is essentially a working hypothesis about the nature of an individual’s
problems that attempts to explain why this person has developed this type of problem
at this point in time and what may be maintaining it. A formulation is less categorical
than a diagnosis and attempts to deal with the question ‘what has happened to you’
rather than ‘what is wrong with you’. Clinical psychologists are trained to formulate
every case that they work with. This may be according to a single modality therapy
(e.g. CBT) or it may be integrative, drawing upon a range of psychological theories
in order to provide the most holistic understanding of the issues the individual is facing.
Johnstone and Dallos’ (2013) book on formulation gives a full guide to all the
approaches. A comprehensive formulation should draw on bio-psychosocial theories
and be consistent with a recovery approach. Understanding a given diagnosis may be
 WORKING IN TEAMS 43

The changing use of language in mental health

Language fundamentally shapes how we see the world, and as we have
gradually changed the framework we have used to understand emotional
distress and mental health problems, we have had to change the way we talk
about people with mental health problems. The following are examples of
currently unacceptable and acceptable language in mental health.

Unacceptable Acceptable
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He is crazy/mad/insane He has a mental health condition

She is a schizophrenic She has a diagnosis of schizophrenia
He is normal/sane He doesn’t have a mental health condition
FOCUS 3.2

She went crazy She felt very emotionally disturbed

Patient (in some settings) Service-user/expert by experience
He committed suicide He took his own life
Mentally handicapped She has a learning disability
Lunatic asylum Acute inpatient unit

an important part of the formulation – but a formulation should encompass more than
that. The formulation may then be used to determine the most appropriate treatment
plan. The British Psychological Society Division of Clinical Psychology has developed
‘Good Practice Guidelines on the use of psychological formulation’ (DCP, 2011).

The bio-psychosocial model

When developing an understanding of the causes of mental health problems, the bio-
psychosocial model of mental illness now provides the most consistently accepted
framework. This model was first described by Engel (1977) as an attempt to move
beyond a purely biological approach to the understanding of all illness. Quite simply,
the model when applied to mental illness requires biological, psychological and social
factors to all be considered in understanding why someone is presenting with particular
symptoms at any point in time. The bio-psychosocial model will include an exploration
of biological factors/diagnosis and may be drawn upon as part of a formulation. The
different aspects of the framework are depicted in Figure 3.1.
It is easy to see how this model fits well within a multi-disciplinary approach, as it
helps to place equal value on the knowledge and skills of the different professions
working together in community mental health teams.

Recovery-orientated practice
Over the past 50 years we have seen a shift away from institutionalised care in large
psychiatric hospitals, to models of community care, and most recently to the adoption
of recovery-orientated practice.
 44 PHILIPPA CASARES AND NICK LAKE

PSYCHOLOGICAL

• Learning • Memory
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FIGURE 3.1 The bio-psychosocial model

The idea of recovery has its roots in the civil rights movements of the 1960s and
1970s and the service-user/survivor movement of the 1980s and 1990s. It is derived
from an acknowledgement of the right to health and well-being combined with the
realisation that institutionalised care and psychiatric practices were failing to support
a person to have a satisfying and fulfilling life alongside any mental health condition.
At the core of recovery-orientated practice is the assumption that people need to
be supported to develop a meaningful and satisfying life, as defined by the person
themselves, whether or not there are ongoing or recurring symptoms or problems.
Recovery, as defined in the recovery model, is not centrally about ‘getting well’ but
is rather about maintaining the highest quality of life in spite of any ongoing symptoms
or difficulties faced. It represents a significant shift in approach for mental health services
and requires a focus on strengths, hope, empowerment, and the development of
meaningful and satisfying roles rather than an exclusive focus on symptom reduction
or management. It has become a key driver in the improvement of the quality of
services to people with severe and enduring conditions.
As part of the adoption of the recovery model within mental health services, service
users are encouraged to develop their own Wellness Recovery Action Plan (WRAP)
as a way of having mastery over their own crises and symptoms, and making sure that
services are meeting their needs rather than overpowering them at those critical times
(see www.mentalhealthrecovery.com for examples). A good summary of the recovery
approach may be found in the Sainsbury Centre for Mental Health Document Making
Recovery a Reality (Shepherd et al., 2008).
 WORKING IN TEAMS 45

The latest development in recovery approaches is the introduction of recovery

colleges which are now beginning to offer a wide range of courses to people with
mental health problems and their carers. The idea is to encourage people to take control
over their own well-being and recovery through peer-supported learning within these
classes or educational workshops. Although still in their early stages, recovery colleges
are seen as extremely empowering.

A CLINICAL PSYCHOLOGIST’S ROLE IN MULTI-DISCIPLINARY

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TEAMS (MDT)

The role of the clinical psychologist in a MDT is not only to provide high-quality
psychological assessment, formulation and intervention to individuals and groups
accessing the help of that team. It is also about supporting and enhancing the
development of good psychological skills and thinking within the team as a whole.
This can be done through the following:

• supervision of staff individually or in groups;

• consultation for staff around complex cases;
• education and training sessions for the team;
• formulation and team formulation sessions;
• reflective practice groups for staff;
• team development sessions;
• supporting high-quality psychologically informed service development.

In this respect, therapy is only one element of the work conducted by a clinical
psychologist. The full range of skills that psychologists are trained in – assessment and
therapy skills, teaching, supervision, consultation, research and audit, clinical leadership
and psychometric assessment combined with a high level of analytical ability – can
and should be used to good effect to support the development of a highly effective
mental health team.
While these indirect ways of working are highly valued by staff (see examples
below), this broad range of work is time consuming and one of the current issues facing
clinical psychology is how to demonstrate the effectiveness and value of indirect ways
of working in the face of increasing demands for individual treatments. This is
particularly the case as services move towards the system of Payment by Results
(www.gov.uk). The document New Ways of Working for Applied Psychologists in Health
and Social Care: Working Psychologically in Teams (BPS, 2007) provides a full description
of all the ways in which psychologists can and should contribute towards effective team
working.

Team formulation
One of the increasingly common ways in which psychologists are contributing to skills
development in teams, and to effective team functioning, is through team formula-
 46 PHILIPPA CASARES AND NICK LAKE

tion (Lake, 2008). ‘Team formulation is the process of facilitating a group or team
of professionals to construct a shared understanding of a service user’s difficulties’
(Johnstone in Johnstone and Dallos, 2013). In developing a team formulation, team
members are encouraged to think together about the service user and to develop a
shared understanding derived from all of their experiences. This information may then
be used to develop a comprehensive care plan where each professional is clear about
their role and how their work contributes towards the treatment package as a whole.
To date there has not been much formal research on the impact of team formulation,
but some of the predicted benefits are: achieving a consistent team approach to
intervention; helping team, service user and carers to work together; generating new
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ways of thinking; drawing on and valuing the expertise of all team members; reducing
negative staff perceptions; raising staff morale, and facilitating culture change in teams
and organisations.
In our services we have been supporting clinical psychologists to facilitate team
formulation with the aim of improving the quality of team working and the care
provided to our service-users. The value of this work is best illustrated by the
following quotes:

‘My experience of the formulation space has been very good and it’s really exciting
for me to see the approach spreading gradually into our culture and general
practice. I think the space itself gives us an excellent framework for establishing
(or re-establishing) the client’s story and background, which allows us to develop
a much more conceivable account of what might be happening for them on a
deeper psychological level. I’ve found it to be a very holistic and person-centred
process. It’s non-stigmatising and I like that it is fluid and open to change/
adjustment. I like that it helps me, as a member of staff, to feel like I know why
things are happening as they are. This not only helps me to feel a much deeper
sense of empathy, it gives me/the team a much more credible basis for establishing
the best form of treatment or intervention for that person. In a nutshell, I think
it raises the standard of care we are able to offer to people and to my mind is what
services should have been doing all along!’
Alex, Support Worker

‘A navigational psychological and clinical compass when you are lost in the
emotional maze created by the chaos of the patient’s past hurts and rejections and
losing your own sense of direction with them. It helps regain perspective and
clinical effectiveness.’
Gail, CMHN

Clinical leadership
New Ways of Working for Applied Psychologists in Health and Social Care (BPS, 2007) is
a document produced by the British Psychological Society that aimed to fully describe
the types of roles and work that a clinical psychologist should be taking on in a modern
NHS. It re-emphasised the importance and value of good, clear clinical leadership in
community mental health services and argued that, as senior members of the MDT,
 WORKING IN TEAMS 47

psychologists should be taking on these clinical leadership roles (e.g. ensuring safe
practice, leading on clinical improvements, negotiating with clinical commissioners,
etc.). As a consequence, developing leadership skills has increasingly been seen as
important for the profession even in initial clinical training. The British Psychological
Society has developed a leadership framework that sets out clearly what is expected
in terms of leadership at all levels (Skinner and Toogood, 2010).

Staff support
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Work in MDTs in mental health care can be rich and rewarding but also challenging
and complex. Staff must hold and contain the highly complex and often challenging
difficulties faced by their clients, manage high levels of risk and deal with the
consequences of suicide and high workload levels, and cope with an ever-changing
and highly complex organisational context due to constant ongoing change within the
NHS. Sometimes these pressures can result in fractious relationships and conflict among
professionals, both within and sometimes between different teams. Understanding this
reality from a psychological perspective in order to support staff and build staff
resilience is another important element of a clinical psychologist’s role. Sometimes
psychologists will provide support and advice to their own team, although a psychol-
ogist must always be wary of offering team support to a team of which they are a part.
More often, a psychologist will be asked to provide support to other teams and services,
acting in a consultant capacity, supporting team building and development, and
providing psychological support to individuals within the team as required. We must
bear in mind that some staff members who are drawn to work in mental health may
be attracted because of relevant personal or family experiences (Casares and Leiper,
2000). For example, they may have been drawn into caring roles within their own
families earlier in life or they may have suffered from their own traumas and difficulties,
leading to a desire to support others through these experiences. This can make them
highly effective as caregivers but also vulnerable to certain stressors, such as experiencing
a particularly high sense of personal failure if someone decides to end their life, a deep
sense of frustration and anger at not feeling cared for themselves in a particular
organisational context (such as another NHS reorganisation), or from burn-out because
of a failure to set boundaries around their caring role.
Clinical psychologists are encouraged through training and beyond to reflect upon
their own processes and to understand and work with their vulnerabilities. They are
increasingly being encouraged to use this knowledge and understanding to help staff
thrive and function in a resilient way in the face of high stress and demand. A good
understanding of attachment theory in relation to work and an appreciation of how
decreasing fear can increase vitality (in the same way that a child who feels safe is able
to play and explore) can be really helpful with understanding and supporting staff
under stress. There is a wealth of literature on resilience and developing team resili-
ence as services have come to appreciate the importance of keeping staff well and
motivated in order to maintain quality and enhance productivity: see McCluskey
(2005) and Frost (2003).
 48 PHILIPPA CASARES AND NICK LAKE

CASE STUDY: SARAH

Referral
Sarah, a 46-year-old art teacher, was referred to one of our local community
assessment, treatment and recovery services following discharge from a three-
month stay in the local acute (inpatient) mental health hospital. She had previously
been diagnosed with bipolar disorder (a condition where someone fluctuates
between very depressed mood to periods of elevated mood and manic behaviour)
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and had become extremely depressed and unmotivated in the months leading up to
her admission. Sarah was married with no children. She had struggled with
depression over the past five years and hadn’t worked for the past four years. Prior
to her admission she had been talking about the possibility of suicide, as she did not
feel that life was worth continuing. Her husband acted as her advocate and full-time
carer, and always accompanied her at appointments to offer his support. She and her
husband were unhappy with the diagnosis and had requested a second opinion.
Based on previous experience, they were both anxious that they would not receive
the support they needed.

Initial assessment
Sarah was seen for a joint initial assessment by a psychiatrist and a female
community mental health nurse. One aim was to review diagnosis and medication
but there was also a recognition that the acute staff had struggled to get close to
Sarah and to develop a shared understanding about what might be contributing to her
current depression. Sarah said initially that she did not believe that talking about her
problems was helpful. However, during the meeting she began to talk about the four
miscarriages she had suffered since her late thirties. She had not talked about this
before with any mental health professional and she became quite emotional during
the meeting.
Despite both members of staff feeling that they had engaged well with Sarah,
Sarah became critical towards the end of the meeting, expressing her feeling that
they had not listened properly and that that they didn’t really seem to care about
what she was experiencing. Both members of staff felt hurt and a little defensive
initially, although both also tried to use her complaint to try to tease out what Sarah
felt wasn’t being heard or understood. Despite this, by the end of the meeting both
members of staff felt unclear about what intervention would best help Sarah.
To help them with this, Sarah’s case was discussed in the team clinical meeting.
The team felt that a further assessment was important to tease out the psychological
issues that might be relevant, and it was agreed that the team psychologist (one of
the authors) would meet her for three further assessment/formulation sessions and
that this would be followed by a team formulation meeting so that the team could
share their knowledge and experience of being with Sarah. Both Sarah and her
 WORKING IN TEAMS 49

husband were happy with this proposal when it was raised in a subsequent
telephone call. The psychiatrist thought that the diagnosis might more reasonably be
reactive depression and altered her medication accordingly.

Further assessment/formulation sessions

I met with Sarah for three sessions. Sarah talked about being the third daughter of
two high-achieving doctors. Her mother had suffered with postnatal depression
following her birth and had left Sarah in the care of her grandmother for much of her
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first year. Sarah described the relationship she had with her mother growing up as
critical, absent and cold. She was closer to her father but he was extremely busy and
often away on call. He also had high expectations of Sarah. Sarah felt that she was a
disappointment to her parents, believing that they had really wanted a son and
someone who was more academic. When she was 13 she discovered that her father
was having an affair with her mother’s best friend. This was a secret that she was
unable to share with anyone. Her two elder sisters followed in her parents’ footsteps
and became doctors, leaving Sarah increasingly feeling like the odd one out. Sarah,
however, had learned from her family not to complain and keep a ‘stiff upper lip’. At
18 Sarah met David, her current husband, who was training to be a doctor. He never
completed his training and they subsequently moved to Australia. Six years ago,
Sarah’s mother died of a heart attack and Sarah and David returned to live in England
after the funeral. It was not long after this that Sarah started to struggle with intense
feelings of depression.

Team formulation meeting

The meeting was attended by the psychiatrist, the psychologist (me), the CMHN,
an OT and a support worker. I facilitated the meeting and everyone had a chance
to share their experience of working with Sarah. I seemed to feel more empathy
with Sarah, perhaps because I had heard her whole story, while the psychiatrist
and CMHN had been left feeling somewhat inadequate and rejected by her after
their first meeting. The whole team felt that despite our good intentions, we
might struggle to meet Sarah’s expectations and we were aware that she had a
tendency to use formal complaints when she felt her needs weren’t being met.
The team reflected on how, if they weren’t careful, this could result in the team
taking an overly defensive stance in relation to Sarah’s care. The team began to
reflect on what might be going on for Sarah. The following formulation emerged
from the discussions.

The formulation
Sarah was abandoned by her mother very early in life and she subsequently
struggled to develop a warm and loving relationship with her. The team reflected
on the fact that this had probably left her feeling that she was not that lovable,
that she wasn’t good enough and that she was possibly the wrong gender. The
 50 PHILIPPA CASARES AND NICK LAKE

anxiety, anger and depression that she would have felt about this as a child would
have needed to be suppressed (defended against) in order to maintain some
emotional connection to her parents and to avoid the overwhelming anxiety of
being abandoned. Moving abroad and maintaining a long physical distance from
her parents probably helped to keep these negative emotions suppressed.
Unfortunately, losing four babies again exposed deep feelings of loss and
exacerbated the awful feeling from childhood of not being good enough. When
her own mother died Sarah’s grief was prolonged and complicated because of
the unresolved issues in that relationship, on top of having to manage the loss of
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her own unborn children. Having not yet discovered a way to express or process
these negative emotions, Sarah found herself overwhelmed by uncomfortable
feelings of anger and grief with no expectation that they could be understood,
held or soothed. In fact, her expectation was the opposite and she expected
criticism and neglect. The team reflected on the fact that she was probably
projecting her expectation of abandonment on to the members of the team who
were trying to offer her support. In order to manage the awful feelings of
unworthiness and unlovability which underpinned these expectations, the team
also felt that she might be unconsciously defending against these feelings by
rejecting those people, and undermining their efforts to care for her, before they
had a chance to reject her.
The psychiatrist reflected that it was interesting that Sarah initially ended up
with a very medical approach to her care in hospital, perhaps paralleling the fact
that describing medical illnesses was one of the few ways of communicating and
meeting needs in her family of origin. Her anger towards the staff could also be
seen as a representation of her anger with both her medical parents and medical
siblings who failed to ‘emotionally care’ for her. It is often the case that it is easier
for service users to express their anger towards staff than towards the original
caregivers upon whom they have been so dependent.

The care plan

Developing a greater understanding of Sarah’s depression, and in particular how
her early attachment relationships and care-seeking behaviour were being
replayed in her interactions with the team, enabled the team to develop a care
plan that was responsive to her individual needs and issues. The key component
was to offer Sarah the opportunity to engage in a psychological therapy that would
enable her to develop an emotional and intellectual understanding of the factors
underlying her depression. One element of this was to help Sarah identify how
her early relationship patterns set up with her parents had contributed to repeated
relationship patterns in the present (i.e. seeing others as rejecting and therefore
sabotaging any connection she might develop to avoid this feared rejection).
These relationship patterns were serving to further maintain her underlying
feelings of inadequacy, her lack of connection to others, and resulted in further
experiences of loss.
 WORKING IN TEAMS 51

A number of other issues were also contributing to her depression, including

isolation, unemployment, and a lack of meaning and purpose in life. The care plan
therefore included the following components:

1 Sixteen sessions of CAT (cognitive-analytic therapy) conducted by the clinical

psychologist.
2 Six sessions of OT interventions to enable Sarah to begin to reconnect with her
local community.
3 A support worker offered to help Sarah with her WRAP plan. Sarah was
encouraged to attend whatever course she liked from the local recovery college.
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She chose a mindfulness course and a ‘coping with your depression’ course. The
longer term plan was to support her return to work. The support worker offered to
take her along to a local art group.
4 Her husband was offered a carer’s assessment by the social worker and some
support.

In addition, this case was highlighted by the psychologist in an education session for
the team. It enabled the psychologist to explore the impact of early attachment
failures, how that may impact upon a client’s care-seeking behaviours, and how we
can use this understanding to meet that person’s needs rather than repeat and play
out an old, unhelpful dynamic (McCluskey, 2005).

Outcome
Sarah engaged in the therapy and after three months began tentatively to create art
pieces again. Her husband felt confident that she was progressing enough to go back
to work himself. Sarah decided to use her teaching skills by becoming a peer teacher
at the local recovery college. She had a brief relapse around the time of the
anniversary of her mother’s death, but with extra support from the support worker at
that time and by using her WRAP plan she was able to avoid a further admission and
get herself back on track. The team began to view Sarah much more positively and
she developed good working relationships with the staff. Sarah was discharged from
the service after eight months of treatment.

Reflections
By understanding the causes of Sarah’s depression and understanding how her early
attachment relationships and care-seeking behaviour were being replayed in her
interactions with the team, the team were able to be more empathic to Sarah’s
distress and provide a comprehensive package of care that was genuinely responsive
to her individual needs and issues. Sarah learned how she unintentionally pushed
people away because of her expectation that she would not be good enough for
them and how she in turn could be quite critical of other people. This enabled her to
shift her style of relating and to find new ways of coping when under stress. She also
learned to be much more comfortable with knowing and expressing her emotions
which reduced her anger towards herself and others.
 52 PHILIPPA CASARES AND NICK LAKE

CONCLUSION

We do the best for our clients when we can successfully harness the knowledge, skills
and experience of the broad range of professionals who work within multi-disciplinary
mental health teams. We hope this chapter has given you a good introduction to what
these different professionals do and what perspectives they bring to the understand-
ing and treatment of human distress. We also hope you will have gained an insight
into the particular roles psychologists play in these teams and that help these teams
to be effective. These roles are just as important as our direct clinical work with
clients. While occasionally challenging and stressful, we have found working as a
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psychologist in multi-disciplinary team settings to be a hugely enriching and stimulating

experience.

LEARNING OUTCOMES

When you have completed this chapter you should:

1 Have an understanding of the role of different professional groups in treating

human distress.
2 Understand the principles underpinning the ‘recovery model’.
3 Understand the principles underpinning a bio-psychosocial formulation of
distress.
4 Understand what diagnosis and formulation contribute to the care and treatment
of people with mental health problems.
5 Have an understanding of how clinical psychologists work with teams and
organisations.

SAMPLE ESSAY TITLES

• Describe the principles of recovery.

• Describe the pros and cons of diagnosis versus formulation. Does one approach
preclude the other?
• How might a psychologist contribute towards effective team functioning?
• What roles do psychologists play in multi-disciplinary mental health teams?

REFERENCES

American Psychiatric Organisation (2013). Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition. DSM 5.
British Psychological Society (2007). New Ways of Working for Applied Psychologists in Health and
Social Care: Working Psychologically in Teams. Leicester: BPS.
 WORKING IN TEAMS 53

Casares, P. and Leiper, R. (2000). An investigation of the attachment organisation of clinical

psychologists and its relationship to clinical practice. British Journal of Medical Psychology,
73(4), 449–464.
Division of Clinical Psychology (2011). Good Practice Guidelines on the Use of Psychological
Formulation. Leicester: BPS.
––– (2013). Position Statement on the Classification Behaviour and Experience in Relation to Functional
Psychiatric Diagnosis: Time for a Paradigm Shift. Leicester: BPS.
Department of Health (2007). New Ways of Working for Everyone. A Best Practice Implementation
Guide. DOH, Care Improvement Services.
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Engel, G.L. (1977). The need for a new medical model: A challenge for biomedicine.
Science,196, 129–136.
Frost, P.J. (2003). Toxic Emotions at Work. How Compassionate Managers Handle Pain and Conflict.
Boston, MA: Harvard Business School Press.
Johnstone, L. and Dallos, R. (2013) Formulation in Psychology and Psychotherapy. Making Sense
of People’s Problems (2nd edn). Abingdon, Oxon: Routledge.
Lake, N. (2008). Developing skills in Consultation 2. A team formulation approach. Clinical
Psychology Forum No. 186. BPS.
McCluskey, U. (2005). To Be Met as a Person: The Dynamics of Attachment in Professional
Encounters. London: Karnac.
Shepherd, G., Boardman, J. and Slade, M. (2008). Making Recovery a Reality. Sainsbury Centre
for Mental Health.
Skinner, P. and Toogood, R. (2010). Clinical Psychology Clinical Leadership Development
Framework. Leicester: BPS.
World Health Organisation (1992). ICD-10 Classifications of Mental and Behavioural Disorder:
Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organisation.
Downloaded by [New York University] at 03:50 14 August 2016

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families
children and
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 4 Working with
children
Mary John
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RACHEL’S STORY

My name is Rachel and I am 15 years old and live with my mother and father and two
brothers who are out all the time, into sport and their girlfriends. My parents, irritatingly,
have become very worried about my weight. They have forced me to see a number of
doctors privately as well as my local GP and now as a last resort they have demanded
that I meet with people at Child and Adolescent Mental Health Services. I don’t want to
be doing this. I am happy going to school part time and being able to avoid doing PE and
games. They say it is not safe for me to do any activity now as my weight is too low.
My parents keep making a fuss about me and keep on about my weight, wanting to
talk to me about why I have lost so much weight and why I have stopped seeing my
friends. They seem to forget that friendship is two-way and they need to contact me
too. I think it’s nice to look great. When one of my so-called friends said I was fat I
thought it was time to lose some weight and now I just want to keep it off. How you
look is really important at our school. If you don’t measure up then you are excluded
from being in the ‘in’ groups and I don’t want to be in any of the others. They are just
odd [people]. I do see that as I have only been at school for lessons and then
immediately go home I have lost touch and they have made new friends, which means
that there is little to talk about. New people have joined the year group and I don’t know
them and don’t want to get to know them, as they will see what a dull and boring
person I am. I used to have friends in my previous school where I was a bit of a rebel
and was always in the middle of things. I used to listen to everyone’s problems and sort
them out but since I moved to this school when I was 13 it all changed.
At school the teachers are okay but don’t really do much to help as I am only in half
the lessons, so it feels as if I have to do all the work outside myself. Mum and Dad have
organised for me to see a tutor to help with the work and I go and see them once a
week or talk to them on the phone. I have always done well at school and want to get
3 A*s for my A levels so that I can become a vet, so when I am not watching TV or a
DVD then I am working or worrying about it.
 58 MARY JOHN

Over the last year my weight has dropped which I am pleased about and I have
managed to get my parents to see that it is easier for me to cook my own food so that
I can make sure that I only eat what I want and that the food is clean and not infected
with other people’s bugs. If this doesn’t happen then I start to worry about it and cannot
stop thinking about it.

SUMMARY
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Growing up is a time of learning, physical and emotional development and quite a few
challenges, even if everything goes well. It is normal for children and young people to be
distressed at times along this journey. For some children, however, distress becomes more
extreme or long-lasting. This chapter sets the scene by highlighting normal psychological
and social development, then describes a range of common psychological difficulties that
may be experienced by children including depression, anxiety, conduct disorders, attention-
deficit hyperactivity disorder (ADHD) and eating disorders. Clinical psychologists can
help as part of a network of services available for children and young people across the
age span and in different settings. The task of the clinical psychologist working with
children is to understand what has caused the distress and what is keeping it going, then
to find a way with the child and their family or other caregivers to improve things. The
chapter highlights theory and evidence that they can draw upon in addressing some of
the most common problems, and illustrates their application in practice with a case example
of a clinical psychologist working with a 12-year-old girl with depression linked to her
experience of diabetes.

INTRODUCTION

Children and young people’s mental health is incredibly important because successful
intervention in early life can prevent a whole lifetime of further psychological
difficulties (Kim-Cohen et al., 2003). This is not only important for the individuals
themselves, but for families’ effective functioning and for society as a whole. It even
makes sense economically, as early intervention could save an enormous amount of
tax payers’ money on helping people later in life with ongoing mental health difficulties
(Centre for Economic Performance, 2012). Clinical psychologists work with children
and young people in a wide range of ways across a large number of different settings
in the community, hospital and residential care. These include working with young
children with physical health problems, children experiencing difficulties with school,
or children who have been traumatised by abuse.
Across all of these lines of work, it is important to understand normal development
and how what is happening for a child or young person is interacting with this. For
example, when a teenager becomes socially anxious, it may be understood as relating
to a difficulty within the normal developmental stage of finding their own identity as
they grow through adolescence. It is usually also important to involve the family, other
carers and members of the ‘system’ around the young person, such as teachers or other
 WORKING WITH CHILDREN 59

professionals. This is because this ‘system’ can sometimes inadvertently be keeping

difficulties going and also because it can be so influential in helping to resolve
difficulties.
Working with children can be very challenging, particularly when dealing with
abuse or neglect, but it is also fun, creative and very rewarding because of the dramatic
difference it can make to people’s lives.

NORMAL CHILDHOOD DEVELOPMENT AND ITS PITFALLS

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Psychological difficulties in childhood always need to be understood in the context

of normal cognitive, linguistic and physical development (see Smith et al. (2011) for
an overview), as well as influences such as culture and gender. This complex interaction
of factors shapes how children and young people express distress and how families
respond. Infants and toddlers typically show their unhappiness through changes in
behaviour; for example, running away, shouting and having temper outbursts, or
refusing to go to sleep. It is difficult for very young children to voice emotional distress
through speech, as the necessary language has not yet been sufficiently developed. As
the child matures, emotional distress becomes expressed in more complex ways as they
are able to communicate through verbal and non-verbal means and to make choices
about when and how to alert others to their distress.
Alongside cognitive, linguistic and physical development, children develop in
terms of their identity and relationships with others. Erik Erikson’s theory of
psychosocial development provides a helpful map to understand this (Erikson, 1950;
1995). Erikson considered that our beliefs, ideals and values, which form our identity,
are constantly changing and are dependent on social interactions. For psychological
well-being, an individual’s personal identity should be well integrated and coherent
across all areas of their life. He defined a series of developmental stages to be negotiated
in order to increase psychosocial competence and avoid self-doubt and anxiety.
Parents or guardians are critical in the early stages for these foundations to be
successfully navigated. Erikson conceived of eight stages across the lifespan with five
stages focused upon childhood and adolescence (See Table 4.1).
If these stages are not negotiated satisfactorily, young people tend to become isolated
and are less able to manage new relationships and challenging situations. How parents
or other carers respond to children as they approach each new life experience provides
them with specific life lessons. Parents can provide support and encouragement, frame
feedback in constructive and positive ways to support the successful negotiation of
challenges and in so doing develop a child’s resilience. Alternatively, they can
inadvertently undermine this process by being overprotective and conveying a sense
of the world as a scary and dangerous place that is best avoided.
Besides parents and carers, peers provide learning opportunities to manage new
situations and new levels of intimacy in adolescence. However, vicious cycles may
occur which inhibit development. For example if a young person sees themselves as
less socially competent than others; they may not take up opportunities for healthy
experimentation and therefore become more isolated. These sorts of challenges then
can lead to emotional distress, including low mood, depression and anxiety.
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TABLE 4.1 Erikson’s five stages of psychosocial development from birth to adolescence
Stage Function Successful resolution Unsuccessful resolution
Outcome
Trust vs. mistrust Development of `trust’ in those Sense of safety and security The world is perceived as
(0–2 years ) caring for him or her inconsistent and unpredictable

Autonomy vs. shame Greater sense of control, and Confidence when acting Sense of inadequacy and self-doubt
and doubt (2–4 years) independence over bodily autonomously
functions and choices (e.g. food
and clothing)

Initiative vs. guilt Ability to assert influence over Confidence to make choices and Self-doubt, lack of initiative and
(typically 4–5 years) one another through play and exert influence guilt
other social interactions

Industry vs. inferiority Gaining a sense of competence Self-worth and discovery of own Lack of motivation, low self-esteem,
(5–12 years) which is secured through the talents and abilities inactivity
positive and constructive
feedback about abilities and
achievements

Identity vs. role Transition to adulthood Form effective relationships and Unable to form relationships with
confusion Developing sense of own identity sense of own place in society varied levels of intimacy and unsure
(13–19 years) in relation to others about own place in the world

Source: Erikson (1950, 1959).

 WORKING WITH CHILDREN 61

WHAT PSYCHOLOGICAL DIFFICULTIES CAN OCCUR FOR

CHILDREN AND YOUNG PEOPLE?

In infancy psychological concerns about children tend to be linked to sleep, feeding,

gaining urinary and bowel control or disruptive behaviour. Between 5 and 26 per cent
of 0- to 3-year-olds have been found to meet diagnostic criteria for some form of
emotional or behavioural difficulty, depending on population sampled and definitions
used (Skovgard, 2010).
Approximately one in ten children and young people aged 5 to 16 suffer from a
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diagnosable mental health disorder (Green et al., 2005). This equates to about three
children in every school class. Some of the most common diagnoses, their key
characteristics and prevalence, as found in a 2004 community survey of families in Great
Britain, are shown in Table 4.2.
Prevalence estimates for the different types of difficulty vary significantly according
to methodology and the criteria for identifying problems. For example, pooling all
studies from 1965 to 1996 that used structured diagnostic interviews showed a much
higher prevalence of depression, at 2.8 per cent for children under 13 and 5.6 per cent
for those aged 13 to 18 (Costello et al., 2006).
Self-harm is common across depression and other difficulties, with one in twelve
children and one in fifteen young people deliberately self-harming, for example, by

TABLE 4.2 Key features and prevalence of common psychiatric diagnoses in children and
young people in Great Britain, 2004
Diagnosis Key features Percentage of
10- to16-year-olds
meeting diagnostic
criteria
Conduct disorders Persistent hostility, defiance and 5.8
disobedience
Anxiety disorders Persistent and disabling fears and 3.3
phobias including the anxiety disorders
listed in Chapter 7, plus separation
anxiety (fear when separated from
parents or caregivers)
Attention-deficit and Disabling difficulties with 1.5
hyperactivity disorder concentration, attention and/or
(ADHD) impulsivity
Depression Persistent and disabling low mood 0.9
or irritability, loss of pleasure, fatigue,
sleep disturbance and thoughts of death
Eating disorder Determined weight loss or recurrent 0.3
binges and food restriction, accompanied
by preoccupation with body weight,
shape or control
One or more 9.6
disorders
Source: Green et al. (2005).
 62 MARY JOHN

taking an overdose or cutting their arms (Mental Health Foundation, 2006). Some
groups of children and young people are especially vulnerable to emotional difficulty,
with 72 per cent of looked-after children (e.g. in care homes or foster homes) and 95
per cent of imprisoned young offenders having a diagnosable mental health disorder
(Green et al., 2004).
While many emotional difficulties resolve themselves naturally, more severe or
persistent conditions can remain stable over time if young people are not provided
with the appropriate interventions. More than half of all adults with mental health
problems were diagnosed in childhood with less than half treated appropriately at the
time (Green et al., 2004).
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Diagnosis
For many children and young people, being assigned a diagnostic label can be
unhelpful as it may remain with them even when they grow and change,
shaping expectations over a number of years, and may become a self-
fulfilling prophesy in other contacts with services. Some of the labels
associated with mental health difficulties can lead to prejudice and stigma in
the wider community. Children and young people have less chance to
influence the process of whether they are given a diagnostic label than
adults, and diagnostic labels can unhelpfully detract attention from social and
environmental factors that may have contributed to the development and
maintenance of the problem. For example, a child diagnosed with conduct
disorder may be seen as requiring ‘treatment’ themselves, rather than
FOCUS 4.1

highlighting domestic violence which may be contributing to the problem. For

some families however, diagnosis can be helpful, as it offers access to
certain educational benefits and social services, or gives the family a way of
uniting against the difficulty rather than blaming problems on an individual’s
character or intent.

AETIOLOGY

The causes of emotional and behavioural difficulties in children may be understood

as the interaction of biological, psychological and social factors.
Biologically, genetic predisposition to some difficulties and development of the brain
both play a role. Many mental health conditions have a genetic component, although
this is a rather general risk factor rather than specific problems being directly inherited
(Rutter, 2002). There is also a clear association between the occurrence of adverse
events in childhood (such as emotional, physical or sexual abuse or neglect) and the
development of the brain in areas that enable abilities to manage one’s own behaviour
and emotions (Stien and Kendall, 2004).
 WORKING WITH CHILDREN 63

Psychologically, there is good evidence that the quality of bonds between children
and caregivers has a significant impact upon later relationships and psychological
welfare. The nature and impact of these bonds are highlighted by attachment theory
(Bowlby, 1969, 1973). According to this theory, if the primary caregiver is not
consistently emotionally available (e.g. owing to ill health) bonding experienced by
the child is likely to be ‘insecure’. This particular form of interpersonal relationship
between carer and child is likely to have a significant, negative impact upon subsequent
relationships in childhood, adolescence, and even adulthood (Sroufe et al., 2005).
Parents and caregivers play a crucial role in enabling children to process emotions and
respond to them. If, however, children are exposed to trauma, and negative parenting
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behaviours such as indifference, rejection and abandonment, this development can be

severely inhibited. This can make mental health difficulties more likely.
Social relationships are also very important to young people’s well-being. Young
people become increasingly influenced by the culture and behaviour of their peers as
they grow up and exposure to negative social experiences such as bullying can have
lasting effects upon psychological well-being.

Whose problem is it anyway?

It is usually a parent’s idea that their child needs to come for psychological
help. Children are often brought along reluctantly to appointments, for
example, because they are behaving in ways that are difficult for others, such
as being withdrawn or aggressive. Parents sometimes see the issues as
being centred on the young person, while the young person themselves may
hold a different view, perhaps seeing the problem as how others are acting
towards them. This process is very different to what occurs for the majority
FOCUS 4.2

of adults who decide themselves when they want to seek help. It is essential
that all family member voices are heard when children and young people
meet a clinical psychologist. In resolving the problem these viewpoints need
to be understood in order to develop a collaborative way forward for the
entire family.

PSYCHOLOGICAL HELP FOR CHILDREN AND YOUNG PEOPLE

When a child or young person is experiencing psychological difficulty, help may be

available from a range of sources, including family, school, social services or health
services. Some of the professionals and services that provide help are described in this
section, including health visitors, school counsellors and Children and Young People’s
Mental Health Services (CYPMHS) – the most usual settings for clinical psychologists
to work with children.
All babies come into contact with a health visitor soon after birth, who has a
responsibility to establish that they are thriving and have basic needs met for love, food
 64 MARY JOHN

and warmth. Health visitors may typically be involved in families’ lives up to and until
a child is 7 years old, monitoring well-being and facilitating access to health, social
and educational services if a need is identified. However, due to the potential demands
on services only the most vulnerable families are seen and supported by these
professionals for an extended period.
Many schools and colleges have chosen to employ a school counsellor who is
available to young people to provide psychosocial education as well as psychological
interventions. Typically, young people will access these services if they have concerns
about family, peer relationships, educational performance, appearance, identity and
bullying. However, if the counsellor or school nurse is concerned that the presenting
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problems need a more intensive intervention a referral will be made to specialist

Children and Young People’s Mental Health Services (CYPMHS) following discussion
with both the young person and their parents or carers (McDougal and Crocker, 2001).
School staff members are important in identifying and supporting young people at times
of emotional distress (Salomon and Kirby, 2008).
Most referrals to CYPMHS are initiated by parents via their child’s general
practitioner or other professionals. CYPMHS’ purpose is to ensure that a compre-
hensive assessment is undertaken to help the family understand the causes of the distress
and to try to reach solutions together. CYPMHS teams include social workers, nurses,
child psychotherapists, art therapists, play therapists, clinical psychologists and psy-
chiatrists. Within these teams clinical psychologists offer direct assessment and thera-
peutic work with children and families, but also work as consultants and supervisors
offering a psychological perspective to others involved in the young person’s care.

Consent for psychological treatment

It is really important that children and young people understand the help they
are being offered and are fully involved in decisions about that help. For most
psychological interventions it is reasonably easy to describe what the
assessment and intervention process entails and easy for an individual to
grasp the consequences of deciding whether to take part or not in this
FOCUS 4.3

process. Under UK law children under the age of 16 can decline an

intervention if they understand what is being proposed and the
consequences of their decision. They can also veto the involvement of their
parents or guardians in an intervention, although if this veto is considered life
threatening, professionals can override this.

THE USE OF THEORY AND EVIDENCE IN PSYCHOLOGICAL

PRACTICE

Clinical psychologists draw upon a formulation-based approach in working with

children and young people, constructing a map of factors contributing to the difficulties
of the individual and/or family to help guide intervention (Johnstone and Dallos, 2013;
 WORKING WITH CHILDREN 65

Manassis, 2014). In particular, working with children and young people requires clinical
psychologists to consider multiple perspectives on problems, as there will almost always
be both an individual child’s perspective and parents’ and other family members’ views
to consider. This may mean drawing upon a combination of systemic, developmental
and individual psychological theories.
Some specific intervention approaches have strong evidence to support their
effectiveness across each of the main diagnostic areas. The evidence base for psycho-
logical interventions in conduct disorder, anxiety disorders, ADHD, depression and
eating disorders is reviewed briefly below. For a more comprehensive review, see
Fonagy et al. (2005).
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Conduct disorder
The role of a clinical psychologist in working with children with conduct problems
will often be to offer a formulation-based perspective that allows the behaviour to be
understood in the context of multiple psychological and social factors, including
family or carer attachments, trauma, underlying neuro-behavioural problems (e.g.
ADHD) and learning difficulties. There are also a number of specific skills-based group
interventions that have been found to help parents and carers be more effective in
preventing and managing the child’s behaviour. For older children group or individual
social and cognitive problem-solving programmes are often offered alongside the
groups to build parents’ skills (NICE, 2013). For the most complex and entrenched
problems, family therapy often involving extended networks of school, social services,
criminal justice and other professionals can be helpful in allowing a coordinated
approach to tackling difficulties (Borduin et al., 2003).

Anxiety
The dominant approach for treating anxiety in children and young people is the
‘Coping Cat’ programme (Kendall and Hedtke, 2006). This 16-session CBT-based
intervention can be delivered to individuals or small groups and is designed to enable
children aged 7 to 13 experiencing generalised anxiety disorder, separation anxiety
disorder or social anxiety disorder to recognise, cope with and reduce their anxiety in
real-life situations. Two sessions for parents are also provided. Explanations are tailored
to the linguistic, emotional and cognitive level of the children receiving the inter-
vention. Two randomised controlled trials have produced promising results for the
intervention (Kendall, 1994; Kendall et al.4, 1997). A later trial appeared to show that
adding a family intervention to the CBT-based intervention enhanced its effectiveness
(Barrett et al., 1996).

Attention-deficit hyperactivity disorder (ADHD)

Psychological interventions for ADHD are based on skills training principles, aimed
at minimising and adapting to difficulties with inattentiveness, hyperactivity and
impulsiveness, to reduce their impact on relationships and educational achievement.
For younger children with ADHD, helping parents to manage and shape the child’s
behaviour has been found to be helpful, through group-based parent education
 66 MARY JOHN

programmes (Montoya et al., 2011). For school-aged children this has been augmented
by group or individual CBT or social skills training, with promising results (NICE,
2008; Hirvikoski et al., 2011). For those with the most severe ADHD these
interventions are often offered alongside drug treatment.

Depression
The psychological approaches with the strongest empirical support for depression in
children and young people are cognitive-behavioural therapy (CBT), interpersonal
psychotherapy (IPT) and family therapy. NICE guidance for treatment of depression
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in children and young people recommends that these approaches are offered for
moderate to severe depression and should last for at least three months (NICE, 2005).
Milder depression may be treated with non-directive supportive psychotherapy, group
CBT or guided self-help. CBT for young people has tended to be based on Beck’s
model of depression, exploring and re-evaluating an overly negative view of self, world
and other people while also scheduling activities likely to give a sense of accom-
plishment and pleasure (Beck et al., 1976; Verduyn et al., 2009). Interpersonal
psychotherapy attends to the relationships young people have and how they are
meeting their needs. Typically, depression in young people is considered to be a
manifestation of the conflict between what they hope for in a relationship and the
reality; this affects mood in a negative way and can lead to depression. Therapy
considers how to change relationships in ways that will impact positively upon how
the young person views themselves and their social world (Mufson et al., 2011). CBT
and IPT are usually delivered on a one-to-one basis with young people but some family
involvement is common alongside this, providing opportunities to challenge beliefs
or change relationships. Family therapy provides families with the opportunity to
explore unspoken issues which may be maintaining the depression for an individual
family member. This is described in more detail in Chapter 6. Recent innovations
include the adaptation of mindfulness-based cognitive therapy (MBCT) for children
and young people. This group intervention is based on cultivating a non-judgemental
attention to present moment experiences, using methods based on Buddhist meditation
practices. A small number of studies have explored its utility to relieve symptoms of
depression in children, with promising results (e.g. Lau and Hue, 2011).

Eating disorders
Both individual and family interventions for eating disorders have shown evidence of
effectiveness. For anorexia nervosa, individual treatments for adolescents based
on CBT, IPT and cognitive analytic therapy (a brief therapy with its roots in
psychodynamic and cognitive theory) have shown promising effects, although further
research is needed (NICE, 2004). These interventions must be delivered alongside
interventions focused specifically on ensuring weight gain, as the severe weight loss
associated with this condition can be fatal. For adolescents with anorexia nervosa, the
strongest evidence supports a specific form of family therapy known as the Maudsley
model, which involves 10 to 20 family sessions over 6 to 12 months, during which
time parents are coached to enforce eating and weight gain in their child. Later, the
adolescent’s move towards a level of autonomy appropriate for their age is promoted
 WORKING WITH CHILDREN 67

as an explicit consequence of the resolution of eating problems (Lock et al., 2001).

For bulimia nervosa a specific form of CBT (CBT-BN) has the strongest evidence of
success. IPT has also shown success over a longer time frame, but with some indications
that it may reduce risk of relapse (Wilson et al., 2002).

Communication and creativity in working with children

Children and young people tend to talk about things in different ways to their
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parents and other adults, using different language. Clinical psychologists

therefore need to listen very carefully to the young person to establish which
words they use to describe their distress and to follow this lead rather than
use adult-determined words. Young people also tend to have less developed
abstract thinking than adults, so psychological ideas in therapy need to be
made concrete by grounding them in the young person’s life experience.
The pattern of communication within sessions as a consequence tends
to be more irreverent and contain more humour than in adult therapy.
Clinical psychologists have to be creative, linking psychological ideas with
FOCUS 4.4

everyday situations to bring the ideas alive for the child or teenager. This will
often mean using a variety of art materials, magazines or websites. For
example, engaging a young person to do something differently may involve
discussing how a film character who faced a similar challenge went about
resolving it.

CASE STUDY

Sian was a 12-year-old girl, referred to the Children and Young People’s Mental
Health Service by her school because of concerns about her well-being. The pastoral
head of her school was perturbed about Sian’s attendance levels, which had
dropped to 82 per cent. Sian lived with her mother Jessica and father John. By the
time of the assessment, a further letter had been received from the diabetic service
expressing concern about Sian’s ability to control her diabetes. Her glycogen levels
were elevated to dangerous levels, suggesting that she was not keeping to her
insulin injections and food controls, which could result in long-term physical
consequences.

Assessment
Sarah, one of the clinical psychologists on the team, offered an initial appointment to
Sian and her family. At the outset of the meeting it was evident that Sian was angry
about having to attend. Her mother, although polite, was upset that the school had
made the referral. Her father and sister sat quietly, appearing to be unsure about the
 68 MARY JOHN

reasons for the appointment. Sian reported that she had been diagnosed with
diabetes when she was 11, just after starting secondary school. This had been an
upsetting time. She said she had enjoyed primary school and had many friends there,
had been working well academically and was enrolled in a range of after-school
activities. She had felt happy and was appropriately independent. Sarah also
established that the family had no previous history of physical or psychological
difficulties.
Being diagnosed with diabetes had led to Sian needing to manage her activity
levels, eat sensibly, and inject herself with insulin twice per day. Her mother said that
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Sian was worried about ‘getting fat’ and confirmed that she had put on some weight
over the past year. Sarah asked the family how Sian felt about all of this, and Sian
was able to reply that she felt upset and angry and did not see the point of living in
this way. John commented that he thought Sian found her mother’s concern about
her health intrusive and annoying, and Sian confirmed that she did not like her mum
‘fussing’ over her blood tests, insulin dosage and diet. However, she was also able to
see that she had become increasingly dependent on her mum’s support to stick to
her diabetes management. Socially, she had become isolated from her previous
friends as they had formed new friendships and although she had tried to join new
after-school activities she was unable to keep these up because she felt exhausted
at the end of the school day.
During the meeting Sian told her family that she had been truanting from school
as she was fed up with her peers who called her names and were making negative
comments about her appearance and weight. She had begun a cycle of eating very
little during the day and then eating excessively when she got home from school.
When talking about this behaviour she became highly critical of herself and stated
that she was useless and that she was ashamed of the fact that she could not eat
sensibly. She was also drinking alcohol when she met up with a male friend. She
described her mood as low, frequently being in tears and finding it difficult to sleep.
Before the first session both Sian and her parents had completed versions of the
Strengths and Difficulties Questionnaire (SDQ), a 25-item self-report measure of
emotional, behavioural and social experiences. Sian and her parents’ responses
showed significant social and emotional difficulties.
Consent was gained to contact the school and the diabetic service to gain
further information. The school reported that Sian was sullen, uncommunicative
and reluctant to join in activities. Their perception was that Sian was constantly
breaking the school rules, flouting the dress code, and was rude and disrespectful
to staff. Academically she was under-performing but her form teacher said she had
the capability of performing within the average range. The diabetic service staff
members were concerned at the enduring nature of her poor diabetes management,
despite significant input from the nursing team. They thought she understood
what she needed to do but that she was resistant to making the necessary changes.
The diabetic nurse involved was perturbed about the school’s response to Sian’s
specific needs.
 WORKING WITH CHILDREN 69

Formulation
Developing an understanding with the family of what might be happening required
the integration of a number of theoretical models; a developmental perspective, with
a systemic and cognitive behavioural understanding of the presenting distress and
dilemmas.
Sian appeared to have a secure attachment with her mother and father, but the
family had not faced any challenges of a similar scale to Sian’s diagnosis and
treatment, which ironically predisposed them to struggle with these challenges –
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there was no map for the family of how to get through it together. The main
precipitant of the current difficulties was the onset of Sian’s diabetes, but the impact
of this was amplified by the fact that she was at a critical developmental point in her
life; at the outset of adolescence, exploring her identity and independence. The
sudden constraint on her life owing to the necessary medical self-care routines and
the current dependence on her mum to help her with this had a significant impact on
her self-esteem and confidence. All of this, coupled with some of the physical effects
of poor diabetes management, had led to a vicious cycle of withdrawal, truanting,
and thinking she was fat and ugly and that no one liked her, which further hindered
her diabetes management and led to further withdrawal from school and her peers.
This vicious cycle amounted to depression.
Unfortunately, the teaching and pastoral teams within the school had not been
able to provide a supportive framework for Sian to manage the medical and social
consequences of her condition. Her mother’s reassurance and control of her
diabetes had an unwitting impact of making Sian feel less capable and more
dependent. A formulation diagram showing the multiple interactions of cognitive,
behavioural and physiological factors that were keeping the problem going, in the
context of the critical incident of the diabetes onset, developmental and systemic
factors is shown in Figure 4.1.

Action plan
Sarah developed an intervention plan with Sian and her family. She offered Sian 12
sessions of cognitive-behavioural therapy to tackle her low mood and to facilitate her
managing her diabetes. She also offered the family a series of family meetings to
facilitate a new way of communicating and supporting each other at this transition
point. The diabetic nurse and clinical psychologist agreed together, with Sian’s
consent, to meet with Sian’s personal tutor and pastoral head at the school to
discuss ways to help the teaching staff become more aware of her psychological and
medical needs.

Intervention
In the individual CBT sessions Sarah and Sian drew a basic formulation diagram
together, identifying the specific negative thoughts that had come up in the first
family meeting and their links to withdrawal, poor management of her diabetes, low
 Family relationships have not been able to respond effectively to Sian’s life stage transition to greater independence and the
Protective factors Vulnerability factors
Strong family connections No previous significant
Capacity to make friends challenges in family
Close family

need to manage her diabetes. School not responding effectively to Sian’s distress and medical needs.
Adolescence prompting desire for greater independence and development of own identity
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Critical incidents
Diagnosis of diabetes
Transition to secondary school

Thoughts
‘I am always going to be like this’
‘I am useless’
Developmental factors

‘No one wants to be my friend’

Systemic factors
‘I am ugly’
‘I can’t do anything on my own’
‘I can’t cope with diabetes’

Behaviour
Truanting from school Emotions
Withdrawing from friends Low mood
Over- and undereating Despair
Drinking alcohol

Physiology
Poor control of blood
sugar levels
Lethargy
Lack of energy
Difficulty sleeping

FIGURE 4.1 Formulation of developmental, cognitive-behavioural and systemic factors

contributing to the onset and maintenance of Sian’s depression
 WORKING WITH CHILDREN 71

mood and lethargy. Sian agreed that it would be a good idea if she could work out a
way to break this vicious cycle. Although Sarah found Sian rather reluctant to engage
at first, they developed a good rapport and worked through part of a workbook called
Think Good – Feel Good together (Stallard, 2002). Sian liked the practical approach of
using drawings and worksheets and discovered that she was overlooking the fact
that the diabetes had not really altered many of her qualities that she felt had made
her popular in the past – friends had liked her because she was caring and funny and
not because of how she looked. She thought she could still be caring and funny even
with diabetes. Sian started to see that it might be worth trying to stop diabetes
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getting in the way of her friendships and her life. Sian and Sarah designed a diary of
her blood tests and worked out what helped and hindered her in doing the blood
tests. Sian was concerned that she would miss out on her friendship group’s
activities if she went to the ‘sick-room’ to do the blood tests. She had not told her
friends that she needed to do this regularly. Sarah helped Sian to think through how
she would tell them and what they could do to help in the process. Informing her
friends had a positive impact upon Sian’s view of herself because they stuck by her
and one friend in particular started coming to the sick-room with her. Sian and Sarah
completed 12 sessions. Each month they met with her parents and fed back on how
this was progressing. This gave Sian the opportunity to show how she had a careful
plan for monitoring and maintaining healthy blood sugar levels and, over time, her
mum was able to step back and allow Sian to manage this more independently.
The school meetings led to an agreement for the diabetic nursing team to offer some
training to staff at their next training day.

Outcome
After three months, Sian’s mood was much improved and she had been inviting
friends over after school. Her parents commented that Sian was more like her old
self. Scores on the SDQ had improved significantly from before intervention. Sian
wondered if all her experience of injections might help her if she decided to work as
a nurse in the future.

CRITICAL ISSUES

Multi-agency working
Effective and safe work with young people requires good communication and
collaboration among agencies, including schools, social services, health and charities
involved in the young person’s life. A number of tragic child deaths (such as the
murders of Victoria Climbié and Peter Conelly) have led to investigations to see how
services might have acted more effectively to step in and prevent them. These investi-
gations have often criticised poor collaboration and communication between agencies,
leading to warning signs being missed or not passed on (e.g. Department of Health
 72 MARY JOHN

and the Home Office, 2003). A Common Assessment Framework (Department for
Education, 2013) has been developed to facilitate better communication. This provides
a common process to be followed by any practitioner when a concern is raised about
a child, and leads to the identification of a lead professional to coordinate integrated
care where several agencies become involved.

Person-centred recovery
The concept of ‘recovery’ for most people means the loss of symptoms. For some
mental and physical health difficulties however, complete loss of symptoms may never
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occur. In these instances the concepts of person-centred recovery, or social recovery, can be
helpful. These promote a broader idea of recovery as meaning a young person being
able to function and engage with life while still having to manage some ongoing
symptoms (Simonds et al., 2013). This can offer a more achievable way forward for
children and young people with the most disabling difficulties, reducing a sense of
failure that may occur through not meeting traditional recovery criteria.
This chapter has shown how clinical psychologists can contribute to work with
children, their families, schools and other agencies, drawing together multiple
perspectives on problems and finding shared ways forward based on psychological
theory and evidence. It is a field that includes tears and anger, but also fun, laughter
and creativity. Success in helping a young person overcome difficulties can free them
from a lifetime of future difficulties, and nothing can give you more job satisfaction
as a clinical psychologist than that.

CONCLUSION TO RACHEL’S STORY

After I met with the psychologist I decided that I could work with her as long as my
parents were not involved in the sessions. I could see that I had to put weight on to
avoid going into hospital but I did not want to work on this. We spent a lot of time
discussing what the goals were going to be and eventually agreed that we would have
two goals: one for me to re-engage with my friends and a second for me to understand
what it would mean if I was to put some weight on. A year later I have been able to
meet up with friends and have started a college course, and am working part time in a
shop. I do feel happier and my weight has gone up a little but I still feel in control. I have
agreed to join my parents in some family therapy sessions, which has been much more
helpful than I thought it would be. It gave us all the chance to talk and say things
without one of us getting in a rage and it has made home life much better.

KEY CONCEPTS AND TERMS

• Erikson psychosocial • Communication with • Recovery

development young people • Ethics
• Anxiety • Depression • Team working
• Coping cat • Shame
 WORKING WITH CHILDREN 73

LEARNING OUTCOMES

On completion of this chapter the reader will be able to:

1 Recognise the features of some common mental health conditions experienced

by children and young people.
2 Describe how children access psychological help.
3 Understand the development of emotional distress in children and the
psychological factors that contribute.
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4 Understand how theory and evidence are used to help children with some of the
most common emotional and behavioural difficulties.

SAMPLE ESSAY TITLES

• What factors need to be considered when understanding how young people present
with emotional distress?
• What are the implications for young people in how they access mental health
services?
• What factors do practitioners need to think about when seeing a young person in
specialist CYPMHS? Give consideration to the developmental issues associated with
childhood and adolescence in your answer.

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 WORKING WITH CHILDREN 75

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 5 Working with
families
Graham Lee and Rosey Singh
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D’S STORY

We are a family of four: Father (F, 47), Mother (M, 43), Daughter (D, 14) and Son (S, 10).
D had a long history of poorly controlled diabetes and hospitalisation, was self-harming,
had difficulty attending school regularly and had been receiving treatment from CAMHS.
M suffers from depression and anxiety and S has become withdrawn. We came to
family therapy having reconciled after a period of six months’ parental separation with
D and S dividing their time equally between parents. D was starting GCSEs and S had
just entered secondary school.
Our family therapy sessions usually involved the family therapist, F, M and D, with
S attending occasionally. These generally took the form of questions and discussions of
historical or present issues, a conversation between two observers who were watching
from another room and a summary at the end. We would often discuss D’s problems
with managing her diabetes and its impact upon the rest of the family, as well as
individual relationships within the family unit and how we communicated with one
another. For example, D was hospitalised and this resulted in an investigation by Social
Services into potential neglect. In turn, this raised questions within the family about how
we should deal with the diabetes centre managing D’s condition as well as the
deleterious impact this has on M’s depression and anxiety. It helped a great deal to
know that we would have a safe place in which to raise our fears and worries without
them becoming a source of confrontation at home. The sessions and observers’
conversations were valuable in helping us understand one another’s perspective,
identifying underlying issues we had not vocalised and also to bring out positives that
we had overlooked.

SUMMARY

Family relationships are very important to our well-being, all the more so when we are
children and entirely dependent upon these relationships. It is not surprising therefore
 WORKING WITH FAMILIES 77

that when children experience distress and psychological difficulty the solutions will often
be found within their families. Systemic practice is a way of working with the ‘system’
of relationships around and including an individual in a family in order to tackle
problems that may be affecting everyone. In some ways it is a very different way of working
from other therapies with individuals. It sees distress and symptoms as emerging from
relationship dilemmas rather than being located with individuals. It is a form of therapy
that is adopted, usually after further training, by some clinical psychologists and by
practitioners from other professional backgrounds. This chapter describes the core features
of systemic therapy and the evidence regarding its effects with children and adults. The
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approach is illustrated with a detailed case study where complex difficulties for several
children in a family were addressed by family therapy and systemic work with other
professionals involved with the family.

INTRODUCTION

We live our lives in and through our relationships, and evidence highlights the value
and priority we place on close family relationships. They define who we are and what
matters most to us. We derive strength and resilience from these relationships and they
closely affect and influence our sense of well-being and our health. When problems
in close relationships occur that are experienced as insoluble or unspeakable dilemmas,
psychological distress is the result. This effect may be seen across all age groups, but
it is particularly pronounced for children and young people, who are largely dependent
upon family to meet their emotional and physical needs.
When working with families, symptomatic behaviours in individual children or
adults such as depression, anxiety or eating disorders are understood as attempts at a
self-cure to a relational dilemma experienced by the sufferer as insoluble or too
frightening for them to speak about. Working with ‘yet-to-be-said’ is a cornerstone
of systemic therapy practice in terms of working collaboratively with families. The
therapist and family thus work together to create the relational conditions in which
family members can feel safe enough to take the ‘risk’ of saying the unsayable. Enabling

Diagnosis
Diagnostic categories, such as those found in DSM V and ICD-10, with their
emphasis on locating the problem within the individual, have pros and cons.
When working with families, diagnoses can sometimes be an unproductive
way to understand distress, which may inappropriately label the individual as
FOCUS 5.1

having some kind of personal deficit. In addition to this, diagnostic categories

can have an unhelpful censoring effect on curiosity beyond the diagnosis.
Because of this, systemic therapists will often use diagnoses only as a
starting point to enable the family to explore what role or function the
symptoms play in the family.
 78 GRAHAM LEE AND ROSEY SINGH

families to take the risk of saying the unsayable inevitably changes the meaning of the
symptoms as well as resulting in shifts in the way family members position themselves
and each other in their relationships. It is as a result of these underlying changes in
the family that the relational issues are resolved and symptoms of distress become
increasingly redundant. For example, a child refusing to go to school may do so because
of an intense fear that their parents will fight and therefore separate while they are
away. Enabling discussion about this in the family can allow the underlying problem
to be dealt with appropriately by the parents, and the apparent need for refusing to
go to school may therefore disappear.
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WHAT IS SYSTEMIC PRACTICE?

Systemic family therapy is an approach to helping people with psychological

difficulties which is radically different from other therapies. It does not see its work
as to cure mental illnesses that reside within individuals, but to help people mobilise
the strengths of their relationships so as to make disturbing symptoms unnecessary
or less problematic.
(Stratton, 2010: 5)

Systemic family and couples psychotherapy is an approach that began to develop in

the 1940s. Its parentage was an unlikely alliance of influences that included psycho-
analysts, cyberneticists (who study regulatory systems, both mechanical and biological,
to explore patterns and connections in communication systems, based on theory
derived from mathematics), anthropologists, linguists, communication theorists and
philosophers. Since these early days systemic family therapy and couple therapy has
continued to evolve into a range of ‘stand-alone’ models which although different from
each other are still based on the same underlying principles. The fundamental assump-
tion of all of these models is that the context in which psychological difficulties emerge
is the unique constellation of relationships within the family and that the meanings
that are given to these ‘difficulties’ are a function of this context. The primary focus
of systemic family and couples therapy is, together with the family or couple, to create
a therapeutic context in which changes in the nature, patterns and functions of
relationships can take place. When achieved, it is these ‘second-order’ changes, in the
personal meaning the problem has for each family member, that effectively dis-solve
or render redundant the psychological problems that brought the family or couple into
therapy.
Systemic practice involves a broad view of interconnected social systems at a range
of levels. Attention is paid to the role of power, diversity and culturally constructed
notions of difference. The psychological impact of life experiences upon families and
systems such as adversity and hardship (employment, poverty, migration, racism) as
well as privilege is actively incorporated into subsequent ongoing formulations within
the work.
Systemic practitioners work flexibly with a wide constellation of people, from
individuals, siblings, couples and families to groups of families, professional networks
and wider organisational systems. Individuals are not viewed as having a monopoly
 WORKING WITH FAMILIES 79

on understanding their life and experiences. Others in relationship with them are
viewed as a resource and will inevitably have a different version of them, seeing and
understanding them in ways that the individual may be blind to. Whoever is worked
with, the systemic practitioner always keeps in mind the impact of change and its effects
on and how it is affected by the broader system and sub-systems.
Common features of the systemic therapies are summarised below:

• Sharing knowledge and expertise with family members about how family systems
and processes operate.
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• Working with each family member in relationship to other family members (e.g.
children in relation to their siblings; children’s relationships with parents; couples
in relation to each other, and families’ relationships with members of their wider
family: grandparents, uncles, aunts, nieces and nephews).
• Working with family members to understand their family culture – their stories,
beliefs and traditions. Working alongside family members to productively enable
them to examine and understand the influence of these narratives upon each of
their lives and their family as a whole.
• Highly skilled question construction and therapeutic actions which aim to help
family members notice potential resources, strengths and options which they may
not have recognised or been harnessing.

Relationships and the brain

Neuroscience research has demonstrated that interpersonal relationships
affect the physiological development of our brain biochemistry, from
development in the womb through to old age. In turn, this physiological
development influences how we engage in relationships with others.
Siegal (1999) outlines how patterns in relationships across our lives
interact with brain biochemistry and thus brain development to shape who
we are. He summarises fundamental principles regarding the plasticity of
neurological development that rest on the two-way influence of patterns of
energy and information flow within the brain and between brains. This
seminal work described in detail how the mind is created from an interaction
of internal neuro-physiological processes and interpersonal experience.
Genetically programmed maturational processes within the nervous system
are shaped by experience, especially interpersonal human interactions, to
impact upon the structure and functioning of the developing brain. He states
succinctly that ‘human connections shape the neural connections from which
FOCUS 5.2

the mind emerges ‘ (p. 2).

For example, disruption to early attachment relationships with caregivers
has been shown to influence a wide range of biological markers in the brain,
including hormone levels and epigenetic changes, which in turn may impact
upon ability to cope with stressful events in the future.
 80 GRAHAM LEE AND ROSEY SINGH

HELP FOR FAMILIES: FAMILY NEEDS AND SERVICE

RESPONSES

The fabric of family life involves a rich array of emotional experience, from joy and
pain to the mundane experiences of day-to-day living. Families love, nurture, squabble,
argue and care for their members, often processing, containing and coping together
with huge pressures, stressors and strains from both within the family and from external
sources. Therefore family life requires members to adapt to new situations, roles and
relationship patterns. Focusing on these relationship patterns at times of transition and
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change is often useful in developing shared understandings of distress.

Particular difficulties, distress and symptoms may arise at transition points in the
family life cycle, i.e. entries and exits to and from the family, children entering school
or moving to secondary school, as well as later life changes related to older age and
increased dependency. At these life-cycle transition points, family members are
required to negotiate significant changes in relation to each other – new expectations
and new roles begin to evolve in families’ relationships; for example, upon becoming
a new parent, a couple’s relationship, to being part of a triangular relationship. This
demands that the couple construct a parenting relationship in order to effectively meet
the needs of an infant. At the same time the couple’s own parents acquire the new
role of grandparents. Changes in familial relationships are required throughout the
family life cycle in order to negotiate successfully the developmental tasks involved in
meeting each family member’s needs. Difficulties for individuals and families as a whole
arise when families are unable to make the necessary relational changes needed to meet
one or other family member’s developmental needs.
The first port of call when seeking help for distressing relationship dilemmas, and
the consequent emerging problems for individuals, will often be the family itself, the
wider family network, and the family’s social and friendship groups. The majority of
families with children with significant psychosocial problems do not seek professional
help, or, if they do seek help, they are unlikely to be able to access it (Offord et al.,
1987; Eyberg et al., 2008). A number of barriers to seeking help from specialist mental
health services have been identified. These barriers are often associated with the
perceived stigma of mental health problems, negative beliefs about provider services,
overly complex referral routes to services, as well as lack of capacity from specialist
services to meet demand (Day et al., 2012).
Psychological and psychotherapeutic help for families is provided in a range of
different settings – within a family’s own home, community services such as GP
practices, child and adolescent mental health settings, Social Services departments and
within specialist services such as psychiatric inpatient units and eating disorder units.
Help for families aims to be family centred and embedded in culturally relevant practice
(Beckman et al.,1994; Hanson and Carta,1995). McWilliam et al. (1995) defined family-
centred practice as: responding to family priorities; empowering family members;
adopting an ecological approach to family work; and showing sensitivity and insight
with families.
Many different types of community interventions have been delivered by
psychologists and family and systemic psychotherapists. Peer-led interventions (where
parents experiencing similar needs are trained and supported to support other parents)
 WORKING WITH FAMILIES 81

have been piloted with the specific intention of increasing helping capacity and
acceptability for families. An example of this type of approach is the Enabling Parents
Enabling Communities project (Day et al., 2012) where local parents were trained to
provide group workshops to help other parents in their own communities. Family and
systemic psychotherapists have developed multi-family groups where multiple families
join a series of groups to seek help about a shared difficulty (e.g. eating disorders)
(Fairbairn and Eisler, 2007).
Some more intensive family-based psychosocial interventions have been developed,
such as functional family therapy, multi-systemic therapy and multi-dimensional
treatment foster care. These interventions have been designed to help families where
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a young person presents with a conduct disorder (a pervasive, persistent pattern of

antisocial behaviour). These intensive interventions are on a continuum of intensity
often provided in community settings and family homes. The emphasis is on
developing positive strength-based family alliances, family problem-solving skills,
parenting strategies and working with the wider network to achieve behavioural
change.
Recent initiatives in the UK have set out to expand the availability and improve
the acceptability of psychological help for children and families. These include the
Children and Young People’s Increasing Access to Psychological Therapies (CYP-
IAPT) initiative, which aims to improve access to help for children experiencing
anxiety and depression by training service staff in cognitive-behavioural therapy and
to support parents, and You’re Welcome (Department of Health, 2011), a set of quality
criteria to ensure that services are welcoming to young people.

USE OF THEORY AND EVIDENCE IN PRACTICE

Effectiveness and different types of systemic therapy

The evidence base for the efficacy of systemic interventions for a range of child- and
adult-focused problems is building. General conclusions from meta-analyses indicate
that for many child and adult mental health problems and relationship difficulties,
families who receive couples or family therapy have better outcomes than families in
control groups receiving a range of ‘usual care’ (Shadish and Baldwin, 2003).
A wide range of different systemically informed interventions have been developed.
Many systemic approaches reviewed by Carr (2009a, 2009b) have integrated ideas
from other theoretical models such as behavioural and cognitive-behavioural
approaches into the work with families. Others, such as Flaskas (2002), have intersected
systemic thinking with psychoanalytic thinking to produce a model that draws on both
modalities.
Currently there are limited studies comparing the efficacy of different forms of
systemic intervention with each other. Initial evidence (Henggeler and Sheidow, 2003)
suggests that there is more similarity and shared practice than difference between the
various treatment approaches. Henggeler and Sheidlow (2003) found similarities in
‘conceptualisation, delivery and procedures’ when they reviewed three different
approaches to adolescent conduct disorder: functional family therapy, multi-systemic
therapy and Oregon treatment foster care.
 82 GRAHAM LEE AND ROSEY SINGH

Stratton (2010), who identified 22 stand-alone models of family therapy, refers to

the similarities between systemic approaches as ‘common ground’, writing that reviews
comparing different approaches find much similarity in practice and little difference
in outcome. An overview of the efficacy of family therapy and systemic practice as it
applies to children and adolescents follows.

The effectiveness of family therapy in children’s and young

people’s services
Carr (2009a) reviewed the literature (selecting meta-analyses, RCTs and experimental
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single case studies) for the efficacy of family therapy and systemic interventions for
children and adolescents. The review adopted a broad-based definition of systemic
interventions, including cognitive-behavioural, structural and strategic approaches to
working with families. Parenting interventions as well as interventions involving family
members and members of the child or young person’s wider network were included.
His review indicates evidence of the effectiveness of family therapy or systemic
interventions either as a stand-alone treatment or in combination with other treatment
modalities for the following:

• Problems in infancy such as sleeping, feeding and attachment.

• Childhood adversity problems such as abuse and neglect.
• Conduct problems, including childhood behavioural difficulties and problems with
substance misuse, and attention-deficit and hyperactivity disorder (ADHD).
• Emotion, mood and risk problems, including anxiety, depression, grief, bipolar
disorder and suicidality.
• Eating disorders such as anorexia nervosa, bulimia and obesity.
• Somatic and developmental difficulties such as enuresis, encopresis (soiling),
recurrent abdominal pain, poorly controlled asthma and diabetes.

The following conclusions may be drawn regarding the current evidence (Carr, 2009a,
2009b: Sydow et al., 2010):

1 Systemic interventions encompassing a broad range of approaches are effective for

a wide range of child- and adult-focused problems.
2 These interventions are relatively brief, usually involving no more than 20
sessions, and can be offered by a wide range of professionals in community-based
settings.
3 Treatment manuals have been developed for many systemic interventions and these
may be used by clinicians with appropriate training and supervision.
4 The majority of systemic interventions evaluated in controlled conditions have
been developed within cognitive-behavioural, structural and strategic models.
More research is needed on social constructionist and narrative approaches which
are widely used in systemic clinical practice.
5 Carr’s review is consistent overall with the role which systemic interventions and
family involvement have had within NICE guidelines for a range of disorders in
childhood and adolescence, including: depression (NICE, 2004a), eating disorders
(NICE, 2004b), attempted suicide/self-harm (NICE, 2004c), bipolar disorder
 WORKING WITH FAMILIES 83

(NICE, 2006), OCD (NICE, 2005a), PTSD (NICE, 2005b) and diabetes (NICE,
2004d).
6 Future research needs to clearly define the intervention used, and common
outcome tools (e.g. SCORE: Stratton et al., 2010) should be adopted to enable
clear comparisons. Research should prioritise evaluations of systemic interventions
for child abuse and neglect, emotional problems and psychosis in young people.

CASE STUDY
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The referral
Joshua (12), Kyle (10), Wayne (8), Charlie (6) and Amber (4 months) were all
referred to Child and Adolescent Mental Health Services (CAMHS) by Social and
Caring Services. All the children, who lived with both parents, Mr and Mrs Smith,
were on the Child Protection Register under the categories of neglect and
emotional abuse. In addition to this, Joshua was displaying aggressive behaviours
at school towards teachers, often spilling into violent outbursts towards his peers.
Predictably these behaviours resulted in an emerging pattern of exclusions.
Wayne was reported as displaying aggressive behaviours at school and at home
and was also struggling with nocturnal enuresis (bed wetting) and diurnal
encopresis (daytime soiling). Charlie was described by the local authority as often
displaying a frozen watchfulness when social workers visited the family home.
Amber was described as thriving. All five children were the subjects of care
orders. The local authority plan was to remove all five children from their parents
and find permanent homes for them elsewhere. At a recent hearing the judge had
ordered that both parents and their five children be referred to CAMHS for family
therapy to provide one last attempt to establish whether any further work could be
done to prevent the breakup of this family.

Formulation
The first meeting at CAMHS was challenging and difficult to manage insofar as Mr
Smith (who had mild learning difficulties) and Mrs Smith were openly hostile, rude
and contemptuous towards the therapist, the process of therapy and the service as a
whole. The children sat in silence, presenting as sullen and uncommunicative, and
giving the impression that they had been instructed not to say anything. Mr and Mrs
Smith made it plain that they were attending as a result of coercion.
Systemic therapists are trained to develop and maintain an acute level of curiosity
towards whatever their clients may be showing them in the words they use, the tone
used to deliver the words, their body language – facial expressions, gestures, use of
space, etc. – and not work to a pre-set professional or clinical agenda. A key question
for the therapist was therefore ‘Why is it important to these parents that they show
this level of hostility and open contempt – what function might it be serving for
 84 GRAHAM LEE AND ROSEY SINGH

them?’ The presenting themes of hostility, contempt for professionals and a deep
mistrust of authority were explored with them over two separate sessions. What
emerged from this was a long and painful history of both parents having been
brought up in family contexts characterised by alcohol abuse, drug abuse, neglect
and physical abuse, punctuated by frequent extended periods in the care of the local
authority.
Mr and Mrs Smith both conceded that their deep mistrust and angry feelings
towards Social Services and social workers had very long roots going all the way back
to their early childhoods. As the discussions progressed it also became clear that it
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was not just their own personal experiences of being in and out of local authority
care but also that their families of origin all had similar strongly held feelings and
beliefs about the local authority, and so there were issues of loyalty to their families
of origin. Mr and Mrs Smith felt that the local authority’s decision to seek to remove
all of their children was a fait accompli which they were totally impotent to influence.
Being sent for family therapy was to them simply the latest example of the
authorities’ attempts to humiliate them further and to demonstrate conclusively that
they were unfit parents. Mr and Mrs Smith’s hostility, anger and contempt, displayed
so openly and unambiguously in the sessions, could now be tentatively reframed as
their last-ditch attempts at preserving some self-respect and dignity in the face of
what they perceived as an overwhelming hostile force.

Intervention
In the two initial sessions it had become clear that family therapy in the way it had
been envisaged would not be possible without addressing the relational issues
between the family and the local authority. The idea of putting the family, the local
authority social worker, the family’s sessional worker, and key staff at the local family
centre into a therapeutic process felt risky to say the least. However, from a
systemic perspective individuals and families inevitably develop ‘relationships’ with
larger and more powerful institutions and organisations and, like any other
relationship, they can become stuck in negative, unproductive patterns of interaction.
Mr and Mrs Smith and the local authority professionals were very reluctant to engage
in this process. However, despite their mutual scepticism they agreed to give it a go.
The court was consulted and they agreed, so long as the original work they
envisaged took place afterwards.
We had five sessions altogether attended by Mr and Mrs Smith, the key worker
from the Family Centre, the children’s social worker and the family’s sessional
worker. The emergent themes in the first two sessions that had to be explored were
mistrust and scepticism of the process, and a belief that this was a complete waste
of time. However, as the sessions progressed a stark interactional pattern began to
emerge characterised by a close mirroring of emotions, cognitions and beliefs
between Mr and Mrs Smith and the professionals. Both sides felt deeply
misunderstood by the other. Both sides experienced the other as hostile and
contemptuous. Both sides experienced the other as mistrustful. Both sides
 WORKING WITH FAMILIES 85

experienced the other as uncooperative. Both sides felt demoralised following their
encounters with each other. Both sides experienced a lack of respect from the other.
Both sides experienced feelings of impotence to influence the other.
After the five meetings involving the family and the professionals, the family went
on to attend a series of ten family therapy sessions roughly a month apart. Perhaps
unusually, the family began the programme of family therapy with a pre-existing level
of trust due to the work done with them and the local authority. Trust facilitates risk-
taking and one of the early major themes to emerge in the therapy with the whole
family was the impact of the cot death of Jade at 8 months, four years previously.
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Joshua and Kyle spoke about this in ways that suggested a significant conflict – on
the one hand, both boys continued to experience strong grief reactions connected to
the loss of their sister; on the other hand, they felt angry feelings towards her,
believing that her death robbed them of their mother. Jade’s death had become
unspeakable in the family and Mrs Smith conceded that she had never spoken to
anyone about this, not even to her husband. Mr Smith confirmed this. It transpired
that this silent prohibitive message that Jade was unspeakable had constrained all
the children from speaking about her and thus appropriately mourning her loss. It
appeared that Mrs Smith had become locked into her traumatic grief at the loss of
her (at the time) only daughter, effectively rendering her emotionally unavailable to
her children and her husband. Mr Smith, who had taken his cue from his wife that
Jade had become unspeakable, spoke tearfully of his bewilderment and confusion at
feeling so disconnected from his wife and children around the death of Jade. The
family used a significant number of subsequent therapy sessions to begin the painful
process of reconnecting with each other around the death of their daughter and
sister. The level of trust in the process had now reached a level whereby the children
in the family, in particular Joshua and Kyle, began to take the risk of expressing their
anger and rage towards their parents. At one point Joshua accused his mother of
caring more about someone who was dead than about either him or his siblings. At
this point Mrs Smith stormed out of the room in floods of tears. To her immense
credit she returned a few minutes later and re-engaged with what was being said for
the first time. The therapist had no need to touch explicitly upon the issue of neglect
or emotional abuse given that the children had found a voice and a sense of enough
safety to confront their parents with the reality of their situation.

Outcome
As the previously unsayable issues began to be voiced and explored, both
professionals and the family experienced a sense of shock as they started to become
detached from their construction of the other and began to develop new and
different understandings of each other’s behaviour. This recognition of the
destructive patterns of mutual influence they had all become locked into created the
conditions for the emergence of a more productive style of relationship between the
family and a larger, more powerful system. Previously Mr and Mrs Smith had
effectively refused to cooperate with either the family centre or the children’s social
 86 GRAHAM LEE AND ROSEY SINGH

worker. With improved mutual understanding between everyone, Mr and Mrs Smith
agreed to regular meetings with the social worker, to attend the family centre
regularly and to begin the family therapy work with themselves and their children.
Throughout the programme of family therapy we had regular liaison meetings with
the local authority staff involved together with the family. The main themes of these
meetings focused on the continuing positive developments in the relationship
between the family and the local authority, and, for the first time, the emergence of a
dynamic of mutual trust in this relationship.
The family remained in therapy for 12 months, during which time their relationship
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with the local authority professionals continued to thrive. Joshua’s aggressive

behaviours at home and at school fell away – his school reported a transformed boy
who was doing well. Wayne’s aggressive behaviours also fell away, as did his
enuresis and encopresis, and Charlie had been reported as having become a
chatterbox.
Shortly before the ending of therapy all five children’s names were removed from
the child protection register, and some eight months after this the care orders on all
of the children were rescinded.
Two years later we heard from the local authority that the family had moved home
and all were continuing to do well.

CRITICAL ISSUES

Culturally sensitive practice

Working with families in ways that are culturally sensitive is extremely important.
However, adopting a sensitive approach to working with families from a different
cultural origin from one’s own is complex. As a therapist, understanding your own
positioning and connection within your own culture and how this differs from other
cultures is vital. For example, in many families from Eastern or Middle Eastern cultures
the primary social unit is the family, whereas in Western cultures it tends to be the
individual – for some cultures patriarchal gendered practices are considered the norm,
whereas in Western cultures such practices tend to be frowned upon and have been
the subject of much feminist critical analysis. When confronted by a family whose
beliefs, thoughts and behaviours pose a challenge to a therapist’s own beliefs and arouse
strong conflicting feelings and thoughts in the mind of the therapist, the therapist needs
to know how to use such challenges to good therapeutic effect. Efforts to be respectful
of the other culture can risk the therapist becoming too passive and feeling overly
anxious about what to say or do next. When this happens the therapist may become
ineffectual or even be experienced as disrespectful.

Expert or reflective-practitioner
Achieving a state of what is called collaborative practice is an outcome of co-creating
the conditions in which a process of authentic co-labouring between therapist and family
 WORKING WITH FAMILIES 87

can take place. Achieving this requires a shift from being an expert practitioner to being
a reflective-practitioner. An expert practitioner is presumed to know regardless of their
felt uncertainties. A reflective-practitioner is also presumed to know but is keenly aware
that they are not the only one with important knowledge. A reflective-practitioner is
also aware that their feelings of uncertainty are a source of learning for themselves as
well as their clients. An expert practitioner tends to hold on to the ‘expert role’ and
works at giving their clients a sense of their expertise. A reflective-practitioner seeks
out connections with their clients’ thoughts and feelings, allowing their client to
develop respect for their knowledge from its evidence in their working relationship.
At the extreme, a practitioner who identifies themselves too strongly as ‘expert’ may
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look for deference and status in their clients’ responses to their professional persona,
whereas a reflective-practitioner looks for a sense of real connection with their clients.

CONCLUSION

Working with families using a systemic approach can enable them to become free from
symptoms of distress by broadening what is talked about and dealt with, the relevant
issues becoming shared family problems with shared family solutions.
Families and children can be helped by a wide range of different types of systemic
practice by clinical psychologists and others. This practice draws upon a range of
theoretical perspectives from cognitive-behavioural, social learning theory, narrative
and social constructionist approaches. There is a need for a better understanding of
which types of help are most useful for which types of difficulty a family is experi-
encing. Future service-related clinical research needs to clearly define the intervention
that is being used, and common outcome tools need to be widely adopted to allow
systematic comparisons of outcomes. This knowledge needs to inform practitioner
training, to be translated into increased access to therapies, and to ensure that these
therapies are acceptable to young people and their families.

D’S STORY: THE CONCLUSION

A particular benefit was the interaction of the family therapy with other care providers,
including a diabetes clinic, social services and school. For example, by signing D off
from school the cycle of unwelcome correspondence and other pressures had been
removed, making the immediate circumstances more manageable.
At times the sessions were difficult for us, both individually and collectively, but
these sessions were probably the most valuable. The process has helped each of us
find our voice and express ourselves more effectively, particularly D and S.
Conflicts still exist between us as a family; we again live in two separate homes.
However, we are better able to resolve these conflicts and many of our original
problems are now resolved. D has markedly improved diabetes control and is now
studying A levels full time, and S has developed a wide circle of friends. We are all in a
better place for family therapy, and value its positive effects upon us as a family and
individually.
 88 GRAHAM LEE AND ROSEY SINGH

LEARNING OUTCOMES

When you have read this chapter you will be able to:

1 Understand that although someone in the family may be diagnosed with a

mental health condition (e.g. depression, OCD, anxiety), in working with families
such diagnoses are used as a starting point for exploring the meaning and
function of the associated behaviours in the context of the family.
2 Appreciate that there are different approaches to the same mental health
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difficulties which often work in tandem with one another. Thus the use of
medication can work alongside work with families by providing a window of
relief or partial relief from symptoms, enabling therapeutic work to take place
more easily.
3 Understand that any patterns of behaviours, thoughts or feelings have to be
viewed in context in order to be understood. People live in and through a
complex web of relationships throughout their lives. The constitutive power of
this web to forge and shape identities is fundamental to systemic thinking and
therapeutic practice with families.
4 Understand that the processes involved in achieving a collaborative relationship
between family and therapist rely on the skills of the therapist to pay attention to
the views and beliefs of all family members, especially when they are in conflict
with one another.
5 Appreciate that when working with families, ‘symptoms’ emerging in one or
more individual family members tend to be understood as an attempt at a ‘self-
cure’ to an unvoiced or unspeakable relational dilemma.

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 WORKING WITH FAMILIES 89

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 90 GRAHAM LEE AND ROSEY SINGH

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adults in 3
difficulty
Working with

psychological
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7KLVSDJHLQWHQWLRQDOO\OHIWEODQN
 6 Working with
depression
Kate Cavanagh and Clara Strauss
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SALLY’S STORY

My name is Sally; I am 36 and live with my partner and two young children in a small
village. Georgia, my daughter, is 3 and has just started pre-school, and Archie is 18
months. Before having children I worked full time as an administrator. I enjoyed my job
and got on well with people at work.
I grew up with my mum, dad and younger brother Toby in a nearby town. When I
was little I was a bit clumsy and didn’t do really well at school. Toby was brilliant at
football and usually got all As in his exams. I was always thinking that I was not as good
as him. My mum used to be really critical of me, saying I should be doing better at
school and be more like Toby.
A few weeks after I started university I began to feel really down and saw my GP,
who prescribed antidepressants. I soon began to feel better, but about six months after
Georgia was born I started to feel really low again and was crying all the time. I stopped
eating and stopped going to the local parent and baby group or meeting up with my
friends. I thought I wasn’t a good enough mum and I would sit at home and dwell on all
the reasons why I wasn’t doing a good enough job. Although my mood improved after a
few months, it has recently become much worse and I am finding it difficult to cope.
Everyone else is coping well and I feel that I am completely useless.

SUMMARY

Depression is one of the most common mental health problems – as many as one in ten
people may suffer from an episode of depression during their lifetime. Depression can
affect anyone, young or old, male or female. Episodes of depression sometimes follow
significant life events or a series of more day-to-day difficulties, but can also emerge for
no obvious reason. Some people experience a single episode of depression and then recover
fully; for others chronic or recurrent episodes of depression may cause difficulties over the
 94 KATE CAVANAGH AND CLARA STRAUSS

life course. Fortunately, there are a number of effective treatments available for depression.
Clinical psychologists often work with people with depression to help them make sense
of their experiences, improve their mood and help them re-engage with their activities
and goals.
This chapter will explore the nature of depression and describe the major psychological
theories and evidence-based psychological interventions for this disorder. We will illustrate
the journey through depression using Sally’s story – a woman struggling with the
transition into motherhood.
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INTRODUCTION: WHAT IS DEPRESSION?

Depression is characterised by persistent low mood and a loss of interest or pleasure

in activities. However, it is also experienced differently by different people. While some
describe depression as a feeling of deep sadness, for others feeling irritable, anxious or
agitated are more common experiences. Some people describe depression as an
absence of emotions such as feeling empty or ‘feeling nothing at all’.
The common psychological symptoms of depression include feeling worthless,
hopeless, guilty and tearful. When experiencing depression people often describe
themselves (e.g. ‘I am useless’), their world (e.g. ‘other people see me as a failure’) and
the future (e.g. ‘nothing good will happen’) in negative terms, and tend to see these
things as fixed, all-encompassing and uncontrollable. This bleak view may be
exacerbated by a tendency towards thinking styles that focus on and maximise the
importance of negative events while ignoring positive experiences. Common thinking
errors in depression include the following:

• Filtering: taking in all the negative details while filtering out any positive aspects
of a situation (for example, dwelling on critical feedback while ignoring compli-
ments).
• Over-generalisation: drawing general conclusions from minimal evidence (for
example, thinking that ‘I am a useless student’ if you get a bad mark on one test).
• All-or-nothing thinking: seeing things as extremes and missing the middle ground
(for example, if your performance isn’t 100 per cent perfect, you see yourself as
a total failure).
• Personalisation: believing that everything is somehow directly related to you (for
example, taking things personally, and taking responsibility for things that are
beyond your control).

People with depression often struggle to recall specific positive memories about
themselves or their experiences which may impair both problem-solving and mood
repair. In addition, depression is associated with over-general recollection of both
positive and negative events, which may have a negative impact upon a person’s sense
of self and their ability to overcome future challenges.
Cognitive difficulties such as a loss of concentration, dwelling on past events and
perceived failings and indecisiveness are also common in depression. These
characteristic thinking processes may place a heavy burden on a person’s psychological
 WORKING WITH DEPRESSION 95

resources and make it difficult to keep up with vocational or leisure activities, and may
also impair social and interpersonal relationships.
Physical changes such as a loss of energy, motivation and sex drive are also common
in depression. Changes in appetite are also common. For some people depression is
characterised by a loss of appetite and associated weight loss; for others increased
appetite, which paired with decreased activities may lead to weight gain. Changes in
sleep patterns are also typical of depression. In some cases people find it more difficult
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Medicalisation of the human experience

We all experience low mood and negative automatic thoughts, at least from
time to time, and most of us probably hold some negative core beliefs. Does
this mean that we all have a depressive ‘illness’? There is increasing
controversy about the medicalisation of what some see as a normal part of
the human condition. For example, in the most recent edition of the
Diagnostic and Statistical Manual (DSM-V, APA, 2013) bereavement is no
longer an exclusion criterion for a diagnosis of major depressive disorder.
Some argue that it is natural and expected to be depressed after the death of
a loved one, and that while we should be caring and compassionate to those
experiencing bereavement it is not helpful to see this as a psychiatric illness
in need of treatment.
It is also the case that depressive symptoms lie on a continuum in the
general population and symptoms tend to fluctuate from day to day. That is,
there is not a clear and neatly defined cut-off between those ‘with
depression’ and those ‘without depression’. This is not to deny the fact that
that some people struggle almost daily with extremely low mood, loss of
pleasure and self-critical thinking. However, it suggests that considering
depression as part of the human experience may be more accurate.
Psychological theories such as those underlying MBCT (see p. 108) do not
distinguish between people with ‘mental illnesses’ and those without.
Rather, these approaches acknowledge that difficult experiences are there
for all of us and that what might be particularly helpful is if we can all learn to
kindly notice, accept and not judge these experiences.
Some clinical psychologists are critical of psychological therapies such as
CBT, as they can locate the problem (depression) in the individual rather than
in the wider society. There is good evidence that levels of social and wealth
inequality are associated with mental health problems such as depression.
FOCUS 6.1

That is, communities with a wider discrepancy between the richest and the
poorest tend to have higher rates of depression than more equal societies.
This has led to the development of community psychology which suggests,
among other things, that we should be treating depression through reducing
wealth and social inequality rather than through treating the individual.
 96 KATE CAVANAGH AND CLARA STRAUSS

to fall asleep or stay asleep (insomnia), while others feel very fatigued or lethargic and
spend more time asleep than usual (hypersomnia).
For some people depression can lead to recurring thoughts of death or suicide, and
people with depression are at higher risk of taking their own life than other people in
the general population.

Diagnosis
DSM-V recognises a number of different mood disorders which are characterised by
episodes of depressed mood or irritability and a loss of interest or pleasure in activities.
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A range of additional psychological, motivational, physical and interpersonal or social

difficulties are also associated with depression.
Symptoms of a major depressive disorder include the following:

• low or irritable mood for most of the day, nearly every day;
• loss of interest or pleasure in activities;
• changes in appetite or weight;
• changes in sleep patterns;
• changes in motor functioning, such as psychomotor retardation or agitation;
• loss of energy or fatigue;
• loss of concentration or decisiveness;
• feeling worthless or guilty;
• feeling hopeless or helpless about the future;
• thoughts of death or suicidal ideation.

A formal diagnosis of depression may be given if you are experiencing five or more
symptoms of depression that are not improving for more than two weeks and this is
affecting your work, study, other interests or relationships with other people. Severity
of depression can vary. A greater number of symptoms, more severe functional
impairment and specific suicidal plans or attempts are associated with more severe
depression.
Episodes of depression may co-occur with episodes of heightened mood and
behavior sometimes termed ‘mania’. In this case a diagnosis of bipolar disorder may
be considered.

EPIDEMIOLOGY

One in ten adults may suffer from an episode of depression during their lifetime
(NCCMH, 2010). Children can experience depression, although this is less common
than depression in adolescence and adulthood. Women are around twice as likely to
be diagnosed with depression than men (NCCMH, 2010). Other risk factors for
depression include a family or personal history of mental health problems including
mood disorders, early adversity, economic and educational disadvantage, negative life
events, ongoing life stress and low levels of close social support (NCCMH, 2010).
Depression often co-occurs with anxiety disorders, personality disorders and substance
misuse (Kessler et al., 2005).
 WORKING WITH DEPRESSION 97

AETIOLOGY

There is no single cause of depression. Biological, psychological, social and environ-

mental factors can all influence an individual’s vulnerability to, and resilience against,
the development of depression. Episodes of depression may sometimes follow life-
changing events, or a series of day-to-day difficulties, but may also emerge with no
obvious trigger. A bio-psychosocial model of the aetiology of depression attempts to
describe how these factors affect vulnerability to depression and how they interact
(Engel, 1977; see Figure 6.1).
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Biological:
e.g. genetics, brain structure,
brain function,
neurochemical factors,
circadian rhythms,
physical health

Social and environmental: Psychological:

e.g. early life experiences, e.g. self esteem, beliefs
life events, life stress, social about self, world and
support and family future, cognitive style,
relationships, friends coping skills, social skills
and peers, economic
circumstances,
education

FIGURE 6.1 A bio-psychosocial model of depression

Biological theories
There is evidence from twin, adoption and family studies that genetic factors may play
a role in the development of depression. While findings among studies vary, recent
estimates suggest that around 30 to 40 per cent of the variance in depressive
symptomatology may be accounted for by inherited factors (Agrawal et al., 2004).
The efficiency of neurotransmitter systems in brain areas may also be associated
with depression. For example, abnormalities in serotonin metabolism are implicated
in depression. Both structural and functional differences in the brains of depressed and
non-depressed study participants have also been noted. For example, depression may
be associated with lower levels of activation in brain areas (e.g. pre-frontal cortex,
 98 KATE CAVANAGH AND CLARA STRAUSS

anterior cingulate cortex) associated with emotional regulation and goal attainment,
and abnormalities in other areas associated with emotional contextualisation and
processing (e.g. hippocampus, amygdala) (Davey, 2008).

Psychological theories
There are a number of different psychological models of depression which propose
that our experiences and how we interpret and react to them play an important role
in the development of depression. Psychological models consider both conscious
and unconscious influences. Psychodynamic models view depression as a largely
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unconscious process which unfolds as a response to loss (Freud, 1917). Cognitive

models of depression emphasise the role of negative beliefs and thinking patterns which
maintain low mood and disengagement from meaningful activity (Beck et al., 1979).
Behavioural theories suggest that depression results from a lack of positive reinforce-
ment of pleasurable and meaningful activities (Lewinsohn, 1974). Attachment theories
highlight the role of early relationships with caregivers as paving the way for patterns
of relationships throughout the lifespan, which may be depressogenic (Bowlby, 1980).
Systemic theories of depression suggest that individuals’ experiences cannot be
understood in isolation, and view depression as a problem within the wider family
system (Dallos and Draper, 2010).

Social and environmental factors

Social and environmental factors may also play an important role in the development
of depression. In early life, traumatic experiences (e.g. abuse, neglect and maltreatment)
may be associated with increased vulnerability to depression, and challenging early life
circumstances such as economic and educational disadvantage are also associated with
increased risk (Kessler et al., 1997). In adulthood, both life events and ongoing life stress
may be the catalyst for depression. Limited relationships with family and friends can
increase the risk of developing depression in adverse circumstances (Teo et al., 2013).
The bio-psychosocial model of depression suggests that it is psychological responses
to adverse life circumstances in the context of a biological vulnerability to low mood
that best explains depression, rather than any one factor alone (Kinderman et al., 2013).
It is important to note that as well as a wealth of research aimed at understand-
ing the factors that put individuals at risk of depression, a complementary body of
work aims to understand what factors help people to remain depression free despite
adversity (Haeffel and Grigorenko, 2007). Protective factors such as secure parenting,
close-confiding relationships, well-developed social and problem-solving skills, and
engagement in meaningful activities and goals may buffer against depression even in
difficult circumstances.

THEORY AND EVIDENCE FOR PSYCHOLOGICAL

INTERVENTIONS

Fortunately, clinical psychologists can offer a range of different options when working
with people experiencing depression. These include one-to-one psychological
 WORKING WITH DEPRESSION 99

therapies, group therapy and supported use of self-help materials. While a wide range
of options are available, much of the work psychologists do is guided by evidence-
based guidelines such as those offered by the National Institute of Health and Care
Excellence (NICE) in the UK. For depression (see Figure 6.2), NICE recommends a
choice between cognitive-behavioural therapy (CBT), interpersonal therapy,
behavioural activation and behavioural couples therapy (National Collaborating Centre
for Mental Health [NCCMH], 2010). For people who decline these options
counselling or short-term psychodynamic therapy may also be considered. When it
comes to relapse prevention, NICE recommend mindfulness-based cognitive therapy
for people who are currently well but who have had three or more previous episodes
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of depression (see critical issues section, p. 108). Some of these therapies are described
below.

Cognitive-behavioural therapy
Cognitive-behavioural therapy (CBT) is a psychological therapy based on the principle
that how we think about a situation has a powerful effect on how we feel and how

Persistent sub-threshold, Guided self-help CBT

mild or moderate symptoms Group CBT

(if fail to benefit

from above)

Individual CBT
Interpersonal therapy
Behavioural activation
Behavioural couples therapy

Individual CBT
Moderate or severe symptoms Interpersonal therapy

(Currently well with three or more

previous episodes of depression)

Mindfulness-based cognitive therapy

FIGURE 6.2 NICE recommended psychological interventions for depression

Source: NCCMH (2010).
 100 KATE CAVANAGH AND CLARA STRAUSS

we act, and in turn that what we do can affect our thoughts and feelings. This approach
to depression was originally popularised by Aaron Beck in the 1970s. There is
evidence that CBT for depression is helpful when offered one-to-one, in groups or
in a supported self-help format.
In CBT the therapist and client work together to understand the client’s experiences
and to overcome overwhelming problems by breaking them down into smaller parts.
Clients learn to identify unrealistic and unhelpful thinking patterns and processes that
may be maintaining their depression, and are taught techniques to challenge and change
these habits in daily life. During therapy clients develop more adaptive ways of thinking
about themselves and their world and learn practical ways to improve their state of
mind on a daily basis.
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Behavioural activation
Behavioural activation (BA) is a psychological therapy based on the principle that when
people become depressed many of their activities function as avoidance or escape from
unpleasant thoughts, feelings or situations. The BA approach was developed by Peter
Lewinsohn, and it focuses on activity scheduling to help clients with depression re-
engage in pleasurable and meaningful activities, so that these can be positively
reinforced. Planned timetables of activity are developed that promote engagement with
both pleasurable and challenging experiences and reduce behavioural and cognitive
avoidance. The client is encouraged to introduce small changes and build up the level
of activity gradually towards long-term goals.

Interpersonal therapy
Interpersonal psychotherapy (IPT) was developed by Gerald Klerman and Myrna
Weissman, based on the idea that psychological symptoms, such as depressed mood,
may be understood as a response to current difficulties in relationships which may in
turn affect the quality of those relationships. Typically, IPT focuses on current
relationship themes such as conflict with another person, life changes that affect how
the person feels about themselves and others, grief and loss, or difficulty in starting or
keeping relationships going. During therapy the client works with the therapist to
understand the reciprocal relationship between interpersonal factors and depression,
and seeks to reduce symptoms by learning to cope with or resolve interpersonal
problem areas.

Behavioural couples therapy

Behavioural couples therapy (BCT) is based on the principle that in some cases
unhelpful patterns of relating within a romantic relationship can cause and maintain
depression. This therapy is offered to couples where one of the partners is experiencing
depression and there is relationship distress. The intervention, developed by Andrew
Christensen and Neil Jacobson, aims to help couples understand how their interactions
may affect one another in order to change and develop more helpful interactions which
may reduce stress and increase support within the couple. The focus of the treatment
is on relieving stress and improving communication; managing feelings and changing
behaviour; solving problems and promoting acceptance; and revising perceptions.
 WORKING WITH DEPRESSION 101

Counselling
Sometimes, the term ‘counselling’ is used to refer to talking therapies in general, but
counselling is also a specific type of therapy in its own right. It was developed by Carl
Rogers, who believed that depression could be alleviated through the provision of a
genuine and empathic therapeutic relationship in which the therapist demonstrates
unconditional positive regard for the client.

Short-term psychodynamic therapies

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Brief psychodynamic therapy is a psychological intervention where the emphasis is on

gaining insight into conscious and unconscious psychic conflicts which are believed
to contribute to depression. The therapy sessions are unstructured and do not involve
an emphasis on skills attainment. The therapeutic relationship is foregrounded as a
vehicle of change, and therapy is non-directive.

Indirect working
As well as offering therapies themselves, it is becoming increasingly common for clinical
psychologists to support other mental health practitioners. This includes training and
supervising psychological therapists (such as CBT therapists) and teaching and
supporting non-therapists (such as community mental health nurses, social workers and
doctors) to use psychological principles in their work.

Improving access to psychological therapies

The Improving Access to Psychological Therapies (IAPT) programme is a
large-scale initiative to extend the reach of evidence-based psychological
therapies and to increase patient choice via investment in the training of
thousands of new therapists in England, alongside a fundamental
restructuring of therapy services and the kinds of interventions they offer.
NICE (2009) recommends a stepped-care approach to the management of
depression; this means that as well as offering traditional one-to-one
therapies for people with depression, these services also offer guided self-
help interventions based on the principles of CBT as a first-line treatment to
many people experiencing mild to moderate symptoms. To date, 3600 new
IAPT therapists have been trained by the IAPT programme and many new
FOCUS 6.2

high-volume services targeting common mental health problems such as

depression have been established which, in their first three years, have seen
one million patients. There is a current expansion of IAPT services to increase
service-user choice from among the range of evidence-based therapies such
as CBT and IPT.
 102 KATE CAVANAGH AND CLARA STRAUSS

CASE STUDY

About a year ago, Sally went to her GP to talk about how she was feeling. Her GP
referred Sally to her local Improving Access to Psychological Therapies (IAPT)
service. Sally met with a clinical psychologist, Fiona, who started by asking Sally
about her current difficulties and her life history.

Assessment
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Fiona wanted to have a good understanding of Sally’s difficulties and of her

upbringing. This would help when drawing upon psychological theories to develop a
shared formulation with Sally. At the time of the assessment Sally said she was
feeling low in mood almost every day but what bothered her more was that she
never felt any pleasure, even about the things that once made her feel happy or
excited. She said it was as if someone had switched off her happiness button. Sally
was very self-critical and would lie awake at night, finding it difficult to sleep, thinking
about why she felt so bad and why she was not a better mother. These thoughts
would just go round and round in her head. Sally felt tired most of the time and
tended to stay at home with her children. She would avoid seeing friends, as she
would then compare herself to them unfavourably.
Her relationship with her partner was good, Sally said, and he was loving and
supportive, but his job involved working long hours and sometimes travelling away
from home. Sally saw her parents about once a week and tried to keep how she was
feeling a secret from them, as she was worried that it would make her seem more of
a failure in their eyes than she thought she was already. Sally’s mother helped with
childcare and shopping but Sally says she tended to be critical of Sally’s parenting
style, often telling her how she should be looking after Georgia and Archie differently.
Sally completed some self-report questionnaires during the assessment. This
included the Patient Health Questionnaire (PHQ-9), a self-report measure of
depressive symptoms. Sally’s score of 22 suggested that she was experiencing
severe depression.

Formulation
Fiona drew upon Beck’s cognitive theory of depression (1979) to help make sense of
Sally’s difficulties (see Figure 6.3). According to Beck’s theory of depression, we all
develop core beliefs early in our lives as a way of making sense of our life
experiences. Core beliefs therefore always make perfect sense when we consider
them in light of someone’s early life experiences. Core beliefs are subconscious,
deeply rooted, fact-like beliefs. They include beliefs about ourselves (e.g. ‘I am
unlovable’), other people (e.g. ‘other people are untrustworthy’) and the world (e.g.
‘the world is dangerous’).
Together, Sally and Fiona identified some of Sally’s core beliefs. In particular Sally
held a core belief that she was useless and not as good as other people. When we
 WORKING WITH DEPRESSION 103

look back at Sally’s early life experiences, this makes sense from Sally’s perspective.
She remembers not doing as well at sport or at school as her younger brother and
she remembers her parents telling her she should be doing better. According to
Beck’s theory, we develop rules in order to cope with our core beliefs. These rules
will often be written in an ‘if . . . then . . .’ format. Sally realised she had developed a
rule ‘If I am successful then I am not useless’. Before having her children, Sally
enjoyed her job as an administrator and performed very well. While she was working,
Sally was therefore able to successfully apply this rule and cope with her negative
core beliefs, keeping them at bay. Beck suggests that rules can help keep core
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beliefs dormant in this way for many years, while the rules are working. However,
problems can arise when rules stop working. Life events may happen that prevent
our rules from working effectively (so-called ‘critical incidents’) and it is at this point
that negative core beliefs may be reactivated.
Sally could see that giving up her job was a critical incident that stopped her rules
working. As a parent she did not see herself as successful and so the core beliefs
that had been dormant for many years became activated. Once activated, Beck
suggested that negative core beliefs would give rise to a stream of negative
automatic thoughts. We all experience a stream of automatic thoughts that are often
outside of our conscious awareness (‘where did I leave my keys?’, ‘I like that song’).
When negative core beliefs are activated however, the content of automatic
thoughts can reflect the content of our core beliefs, giving rise to a stream of
subconscious, negative automatic thoughts. Sally could easily see how this applied to
her and could identify a long list of negative automatic thoughts. According to Beck,
in depression these thoughts are seen to trigger and then maintain feelings of low
mood and can lead to changes in behaviour, such as Sally avoiding seeing her friends
as she thought she was not as good as them. More recent research suggests that
there is a reciprocal relationship between negative automatic thoughts and low
mood, whereby low mood can increase the frequency of negative thoughts and then
negative thoughts can maintain low mood. In this way a vicious cycle may be
established between low mood and negative thinking.
Fiona and Sally drew up a diagram to try to show how all of these aspects fitted
together (Figure 6.3).

Action plan
According to Beck’s cognitive theory of depression, negative automatic thoughts and
negative core beliefs are seen to cause and then maintain depression. Cognitive
therapy for depression therefore aims to improve mood and well-being through re-
evaluating negative thoughts, rules and core beliefs, and to establish more accurate
and helpful core beliefs in their place. Fiona and Sally drew up a therapy action plan
that began with an initial phase of monitoring negative automatic thoughts, then re-
evaluating their accuracy, then moving on to re-evaluating underlying negative core
beliefs before finally identifying and strengthening alternative, more accurate and
balanced core beliefs.
 Early experiences
• Critical parents
• Younger brother excelled academically
• Sally had academic difficulties at school

Core beliefs
• I am useless
• Other people are strong and capable
• Other people are critical
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Rules (for coping with core beliefs)

• If I am successful then I am not useless
• If I avoid people then they won’t know I am
useless

Critical incidents
• Starting university
• Giving up job

Automatic thoughts
(“stupid me,
I’m late again”)

Behaviour
Bodily sensations (avoiding friends,
(tired, no appetite) staying at home,
dwelling)

Feelings
(low mood, lack
of pleasure)

FIGURE 6.3 Beckian longitudinal formulation of Sally’s experiences of depression

Source: Adapted from Fennel (1989).
 WORKING WITH DEPRESSION 105

Intervention
The National Institute of Health and Care Excellence recommend between 16 and 20
sessions of cognitive-behavioural therapy for depression (NICE, 2009). Fiona and
Sally agreed to meet for 16 sessions.

Sessions 1 to 3
During the first three sessions Fiona and Sally used thought records to help Sally
recognise the stream of negative automatic thoughts that she had previously not
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always been aware of. Thought records are diaries that encourage us to notice and
write down our thoughts and feelings. An example of a thought record is shown in
Figure 6.4.

1. Situation 2. Moods 3. Automatic thoughts (images)

Who? What did you feel? What was going through your mind
just before you started to feel
What? Rate each mood (0–100%) this way?
When?

Where?

At home with Georgia and I shouldn’t let them watch

Archie on Tuesday Guilty (80%) so much TV
afternoon. I put them in I’m a really bad mum for
front of the TV for a couple letting them watch TV
of hours so I could get on I bet none of my friends
with some housework. Low (70%) would do this

FIGURE 6.4 Three-column thought record

Source: Greenberger and Padesky (1995).

The thought record allowed Sally to write down the day and time when she
noticed a change in her mood, to make a note of her feelings and their intensity, and
to write down automatic thoughts that were in her mind just before or at the time of
the mood change. Sally completed these records between therapy sessions and
Sally and Fiona would discuss the records during their sessions.

Sessions 4 to 6
In the next three sessions Sally used a longer thought record (see Figure 6.5) that
allowed her to identify the automatic thought that was most strongly associated with
the change in mood (often called a ‘hot thought’) and then to carefully consider and
write down evidence supporting and not supporting her hot thought (see
Greenberger and Padesky (1995) for examples). It is interesting to see that Sally was
encouraged to write down evidence supporting her hot thought. This is because we
can think that our hot thoughts are based on good evidence and so it is only by
closely examining this evidence that we can really see if the evidence supports our
thoughts. After carefully writing down evidence for and against a hot thought, Sally
 106 KATE CAVANAGH AND CLARA STRAUSS

1. Situation 2. Moods 3. Automatic 4. Evidence that 5. Evidence that 6. Alternative/ 7. Rate moods now
thoughts (images) supports the hot does not support balanced thoughts
thought the thought
Who? What did you feel? What was going Write an alternative Re-rate moods listed
through your mind or balanced thought. in column 2 as well
What? Rate each mood just before you started as any new moods
(0–100%) to feel this way? Rate how much you (0–100%)
When? believe the alternative
or balanced thought
Where? Circle hot thought (0–100%)

On Wednesday Embarrassed I’m always late Georgia’s The playgroup They are used to Embarrassed
I was late (90%) No one else is keyworker leader was really people being late (20%)
dropping ever late didn’t smile friendly and and don’t
Georgia at at me said not to worry really mind
playgroup Guilty (70%) I bet they think about being late (40%) Guilty (20%)
I’m useless
Last week I saw
another mum
was late
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dropping off
her son

FIGURE 6.5 Seven-column thought record

Source: Greenberger and Padesky (1995).

was encouraged to identify an alternative, balanced thought that fitted the evidence.
Here we can see that Sally is not simply encouraged to ‘think positive’; rather she is
encouraged to identify a thought that accurately reflects all the evidence. Once she
had identified an alternative thought Sally was encouraged to undertake behavioural
experiments to test out the accuracy of these new thoughts. A behavioural
experiment is a way to test out the accuracy of our thoughts and beliefs by predicting
what will happen if our thoughts/beliefs are true, and then reviewing what really
happens and what this means about the accuracy of our thoughts and beliefs. Sally
asked her partner to help her conduct behavioural experiments.

Sessions 7 to 12
In these sessions Sally began to work with her rules and core beliefs. Initially this
involved using techniques to more fully identify core beliefs and rules. Sally used a
record form similar to the thought record, but this time she wrote down experiences
and evidence that did not support each of her negative core beliefs. Because core
beliefs are often held as fact-like beliefs and have been in place since childhood, it
can be difficult to notice evidence that does not support them. So Sally asked her
partner and a close friend to help her recognise evidence. As well as looking at
evidence not supporting her negative core beliefs in the present Sally was also
encouraged to look for evidence throughout her life going back to childhood, and to
conduct behavioural experiments to test out the accuracy of these beliefs.

Sessions 13 to 15
During sessions 13 to 15 Sally considered all the evidence on her core belief
records and together with Fiona used this to explore alternative perspectives that
accurately reflected the evidence. These new ideas about herself were that Sally
was as good as other people and that she was competent and respected. During
these sessions Sally began to notice and write down evidence supporting these
new perspectives.
 WORKING WITH DEPRESSION 107

Throughout sessions 7 to 15 Sally was encouraged to undertake behavioural

experiments to test out the accuracy of her old, negative core beliefs and of her
newly emerging core beliefs. Her husband supported Sally in conducting the
experiments and in reviewing the evidence from these experiments. In their
therapy sessions Fiona and Sally would carefully review the outcome of these
experiments and consider what they meant. Sally started meeting up with old
friends, rejoined the parent and baby group, and started making enquiries at her
old place of work about part-time admin assistant jobs.
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Session 16
In the final session Sally and Fiona reflected upon Sally’s progress through therapy
and drew up a therapy blueprint to act as a quick reminder for Sally of everything
she had learned during the therapy so that she could refer to it in the future.
Sally’s PHQ-9 score at the end of therapy was 14, which is in the mild clinical
range. Although showing an improvement from the initial assessment, it
suggested that Sally was still experiencing some symptoms of depression. Sally
confirmed that she felt less low in mood and was beginning to enjoy things she
had enjoyed in the past, such as being with friends. However, she said that she
still sometimes felt low and found herself caught up in dwelling on her negative
automatic thoughts and low mood.

Team working/indirect work

During the course of therapy, Sally had a number of meetings with Steve, an
employment specialist in the IAPT service. Steve’s job was to support clients in
the service in returning to work. One day Steve asked to speak to Fiona to say he
was puzzled that although Sally seemed keen to return to work she seemed to
reject all of his suggestions and that he was beginning to feel frustrated.
With Sally’s permission, Fiona arranged to meet with Steve the following week
to share the formulation they had developed and to consider why Sally might be
reluctant to follow Steve’s suggestions. Steve found this very useful and it helped
him to understand that Sally might be ambivalent about returning to work because
she was worried that she would not succeed in a new job, which would confirm
her core belief that she was useless.
Sally then had a joint meeting with Fiona and Steve to consider her job seeking
in light of the formulation. This helped them all to see Sally’s job seeking as a
behavioural experiment to test out her newly emerging core beliefs that she was
competent, respected and as good as other people. From this point forward Sally
was able to follow Steve’s advice and she attended a couple of job interviews,
one of them resulting in a job offer for a part-time administrator. Sally was
delighted and surprised with this offer, and in their next therapy session Fiona and
Sally were able to review what this meant in relation to Sally’s core beliefs. The
job offer became evidence for Sally to strengthen her newly emerging core
beliefs.
 108 KATE CAVANAGH AND CLARA STRAUSS

CRITICAL ISSUES

Relapse and depression

While many people who experience an episode of depression will recover fully and
never experience depression again, for some people depression may present difficulties
over the life course. As the number of episodes of depression increases so does the risk
of subsequent episodes so that once someone has experienced two episodes of
depression they have an 80 per cent risk of experiencing another episode.
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While both psychological and pharmacological interventions can be helpful for

depression in the short term, studies usually do not follow participants up beyond a
few months after the intervention has ended. Therefore it is not at all clear how
effective psychological interventions are at protecting people from relapse in the long
term. There is some evidence that CBT is more effective than medication at reducing
the risk of relapse, although more research is needed.

Mindfulness-based cognitive therapy (MBCT)

Mindfulness-based cognitive therapy (MBCT; Segal et al., 2002) is a therapy that
incorporates mindfulness practice and principles with cognitive therapy. Mindfulness
refers to the ability to fully notice our current experiences (thoughts, feelings, bodily
sensations) while being kind, accepting and non-judgemental of these experiences
(Bishop et al., 2004). MBCT was designed as a relapse prevention intervention for
depression for people who are currently well but who are at risk of relapse.
MBCT differs from cognitive therapy in that while cognitive therapy is interested
in identifying and changing the content of thoughts and beliefs, MBCT is interested
in developing a different way of relating to this content. The theory underlying
MBCT is that it is not the content of negative thoughts and beliefs that is distressing;
rather it is how we respond to these experiences. Rumination is the tendency to think
about negative thoughts, feelings and their consequences over and over again; to get
lost in the content and to be attached to the content (Nolen-Hoeksema, 2000). MBCT
sees rumination as the problem rather than the content itself. During MBCT people
engage in mindfulness meditation practices and learn through practice to take a step
back and to observe all experiences (including thoughts) at a distance, to not judge
these experiences as good or bad or as right or wrong and to mindfully make decisions
about how best to respond, rather than responding in potentially unhelpful ways.
In this way, MBCT can help people to let go of ruminative ways of responding to
negative thoughts.
There is evidence from randomised controlled trials that MBCT in comparison to
usual care is effective at reducing the risk of relapse for people who are currently well
and who have experienced three or more previous episodes of depression (Kuyken
et al., 2008; Ma and Teasdale, 2004; Teasdale et al., 2000). It is also becoming
increasingly clear that the benefits of MBCT extend beyond preventing relapse in that
it can help to reduce symptoms of a current depressive episode (Van Aalderen et al.,
2012).
 WORKING WITH DEPRESSION 109

CONCLUSION TO SALLY’S STORY

After I finished working with Fiona we agreed that I would try a mindfulness-based
cognitive therapy (MBCT) group. Fiona said that this can help to keep people well who
have been depressed. During the course I learned to take a step back from my negative
thoughts and I learned to just observe these thoughts as thoughts, rather than as facts.
This meant that I was more able to accept negative thoughts and not to get caught up in
worrying about them or what they meant. I am now more able to let thoughts pass into
my mind and pass out again, without getting lost in my thoughts. I have also become
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more aware of making choices about what I do, so that if I notice thoughts such as
‘Emma won’t want to see me so I’ll call and cancel’ I can now let go of the thought and
meet up with my friend. Although I still have negative thoughts and can sometimes feel
low this doesn’t have the power over me it once had and I can just get on with my life. I
am now back at work, which I find really rewarding, and spending more time with my
family and friends.

KEY CONCEPTS AND TERMS

• MBCT • Core beliefs • Relapse prevention

• Mindfulness • Negative automatic • Diagnosis
• Cognitive therapy thoughts • DSM V

LEARNING OUTCOMES

When you have completed this chapter you should be able to:

1. Know what features or symptoms are characteristic of depression and have an

awareness of the types of psychological difficulties suffered by people
experiencing depression.
2. Have an understanding of the psychological and societal impact of depression.
3. Have an understanding of the psychological theories or models that are relevant
to depression.
4. Have an understanding of the treatment approaches used by clinical
psychologists to treat depression – and the evidence base for these approaches.
5. Have an understanding of how assessment, formulation, intervention and
evaluation may be used in a psychologist’s work with a specific case of
depression.
6. Be able to provide a critical appraisal of the different intervention approaches for
depression.
 110 KATE CAVANAGH AND CLARA STRAUSS

SAMPLE ESSAY TITLES

• Compare and contrast Beck’s cognitive theory of depression with the principles
underlying mindfulness-based cognitive therapy.
• Describe the stress vulnerability model of depression.
• Mindfulness-based cognitive therapy should be offered to everyone with depression.
Discuss.
• It is helpful to think of depression as an illness. Discuss.
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REFERENCES
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study of sex differences in depressive symptoms. Twin Research, 7, 176–181.
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Disorders (5th edn). Arlington, VA: American Psychiatric Publishing.
Beck, A.T., Rush, A.J., Shaw, B.F. and Emery, G. (1979). Cognitive Therapy of Depression. New
York: Guilford Press.
Bishop, S.R., Lau, M., Shapiro, S., Carlson, L., Anderson, N.D., Carmody, J. and Devins, G.
(2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and
Practice, 11, 230–241.
Bowlby, J. (1980). Attachment and Loss, Volume 3: Loss; Sadness and Depression. London:
Random House.
Brown, T.A., Campbell, L.A. and Lehman, C.L. (2001). Current and lifetime comorbidity of
the DSM–IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal
Psychology, 110, 585–599.
Dallos, R. and Draper, R. (2010). An Introduction to Family Therapy (3rd edn). Buckingham:
Open University Press.
Davey, G.C.L. (2008). Psychopathology. Chichester: Blackwell.
Engel, G.L. (1977). The need for a new medical model: A challenge for biomedicine. Science,
196(4286), 129–136.
Fennel, M. (1989). Depression. In K. Hawton, P.M. Salkovskis, J. Kirk and D.M. Clark (eds),
Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide (pp. 169–234). Oxford:
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Freud, S. (1917). Mourning and melancholia. Standard Edition, 14(239), 1957–1961.
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the Way You Think. London: Guilford Press.
Haeffel, G.J. and Grigorenko, E.L. (2007). Cognitive vulnerability to depression: Exploring risk
and resilience. Child and Adolescent Psychiatric Clinics of North America, 16, 435–448.
Kessler, R.C., Davis, C.G. and Kendler, K.S. (1997). Childhood adversity and adult psychiatric
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Kessler, R.C., Chiu, W.T., Demler, O. and Walters, E.E. (2005). Prevalence, severity, and
comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey
Replication. Archives of General Psychiatry, 62(6), 617.
 WORKING WITH DEPRESSION 111

Kinderman, P., Schwannauer, M., Pontin, E. and Tai, S. (2013). Psychological processes mediate
the impact of familial risk, social circumstances and life events on mental health. PLoS ONE,
8(10): e76564. doi:10.1371/journal.pone.0076564.
Kuyken, W., Byford, S., Taylor, R.S., Watkins, E., Holden, E. and White, K. (2008).
Mindfulness-based cognitive therapy to prevent relapse in recurrent depression. Journal of
Consulting and Clinical Psychology, 76, 966–978.
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Ma, S.H. and Teasdale, J.D. (2004). Mindfulness-based cognitive therapy for depression:
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and Clinical Psychology, 72, 31–40.
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(updated edn). Leicester and London: The British Psychological Society and the Royal
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clinical guideline 90. Available at www.nice.org.uk/CG90.
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anxiety/depressive symptoms. Journal of Abnormal Psychology, 109, 504–511.
Segal, Z.V., Williams, J.M.G. and Teasdale, J.D. (2002). Mindfulness-based Cognitive Therapy for
Depression. New York: Guilford Press.
Teasdale, J.D., Segal, Z.V., Williams, J.M.G., Ridgeway, V.A., Soulsby, J.M. and Lau, M.A.
(2000). Prevention of relapse/recurrence in major depression by mindfulness-based
cognitive therapy. Journal of Consulting and Clinical Psychology, 68, 615–623.
Teo A.R., Choi, H. and Valenstein, M. (2013). Social relationships and depression: Ten-year
follow-up from a nationally representative study. PLoS One, 8(4): e62396.
Van Aalderen, J.R., Donders, A.R.T., Giommi, F., Spinhoven, P., Barendregt, H.P. and
Speckens, A.E.M. (2012). The efficacy of mindfulness-based cognitive therapy in recurrent
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 7 Working with
people with anxiety
disorders
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Alesia Moulton-Perkins, Adrian

Whittington and Melissa Chinery

MILLIE’S STORY

My name is Millie. I’m 42 and have worked as a hospital radiographer since 1998. This is
when my washing problems started and I became aware of the obsessive compulsive
disorder (OCD) that was to rule my life for the next thirteen years.
The first time it happened was in the operating theatres. Going for my break I went
to the scrub room, washed my hands and opened the door. In the kitchen I washed my
hands again because I had touched the door. I made my tea and washed again because
I had touched the fridge and kettle.
It felt like something was hanging off my thumb and forefinger. Until I had wet ‘it’
(whatever ‘it’ was!) I couldn’t use them because I felt like everything I touched would
be contaminated. I never had to scrub: simply touching something wet and rubbing
them together would remove the ‘thing’. Getting a parking ticket from the machine at
work was an issue, I was happy if it had rained as I could wipe my finger and thumb on
the machine to wet them. One day I used snow.
It wasn’t the wiping but more the thought processes involved and the time wasted
trying to avoid touching things. Working in a busy department was tricky, watching
colleagues touching everyday objects that had dropped on the floor and not cleaning
their fingers. Eventually I wasn’t comfortable touching patients’ beds, or door handles –
I would kick the doors open to save touching them! The rituals became relentless.

SUMMARY

Anxiety is a normal and useful part of life, helping guide us to avoid danger. However,
anxiety becomes a problem if it persists when we are not in situations that present real
threat. If this continues for some months we think of the anxiety as having become an
 WORKING WITH ANXIETY DISORDERS 113

‘anxiety disorder’. There are lots of different types of anxiety disorder but they all have
in common that they are linked to a persistent perception of threat or danger that is
exaggerated beyond the actual level of danger. Anxiety disorders are the most common
mental health problems, with more than one in ten people suffering from an anxiety
disorder at any moment in time. Anxiety disorders can be very persistent if not treated,
and most people never receive any treatment. However, there are psychological treatments
that can be delivered by clinical psychologists and others, which have a very good track
record of success.
This chapter outlines the nature of anxiety disorders and the main evidence-based
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treatments. It then presents an example of how a clinical psychologist helped one client,
Jim, to make significant progress in overcoming the difficulties he was experiencing as a
result of generalised anxiety disorder.

INTRODUCTION: WHAT ARE THE TYPES OF PSYCHOLOGICAL

DIFFICULTIES THAT MAY OCCUR IN ANXIETY DISORDERS?

Everyone experiences anxiety at times. It is a normal reaction to threatening events

or circumstances and its presence has obvious survival and therefore evolutionary
advantages, driving organisms to escape or avoid real danger. People who are
moderately anxious tend to perform better than those with very low or very high
anxiety, for example, when giving a talk or attending an interview (Yerkes and Dodson,
1908). However, anxiety can become a problem when it is persistent, interferes
significantly with daily life and is out of proportion to the actual danger in a situation.
This sort of trouble with anxiety is often a sign of an anxiety ‘disorder’.
What is it like to have an anxiety disorder? Clark and Beck’s (2010) cognitive-
behavioural model of anxiety describes anxiety in terms of four response systems:
cognition, affect, physiology and behaviour.

Cognitions
Cognitions may take the form of thoughts (persistent or fleeting) or mental images.
People with anxiety disorders tend to be troubled by cognitions that are focused on
present or future threat. For example, someone with panic disorder may have the
thought ‘If I keep breathing this fast I will pass out’. Someone with OCD may
fleetingly think ‘If I touch this door handle I could catch a disease and pass it on to
my daughter’ – a thought that may be accompanied by a mental image of the daughter
in a hospital bed. These thoughts and images are often highly believable to the person
experiencing them, even though they are not accurate representations of the true
degree of threat.

Affect
Thinking this way it is easy to see how someone may feel fearful, apprehensive, stressed
or agitated. This would be a healthy and useful response if the thoughts were true.
 114 ALESIA MOULTON-PERKINS ET AL.

Physiology
Anxiety can trigger the bodily ‘fight-or-flight response’ where a release of the hormone
adrenaline leads to body sensations such as fast breathing, racing heart or sweating. All
of these reactions prepare the body to fight or flee the source of perceived danger and
are themselves harmless.

Behaviours
When anxious, people often try to avoid, escape from or neutralise the perceived
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threats. For example, someone with agoraphobia may avoid crowded shops because
once before they had a panic attack in one. Staying at home and doing internet
shopping feels safer. If forced to stay in the situation they may do something that makes
them feel safer (e.g. checking where the escape route is or taking deep breaths).

DIAGNOSIS

DSM-V and ICD-10 list numerous different anxiety disorders, each with specific signs
and symptoms. Table 7.1 lists seven of the most common anxiety problems and
highlights key symptoms. Typically, diagnosis of any of these disorders requires the
presence of a defined number of symptoms, on more days than not, across a defined
period of time (usually six months).

EPIDEMIOLOGY

Anxiety disorders are the most common of all mental disorders. The British Psychiatric
Morbidity Survey measured prevalence of mental disorders in adult households
(McManus et al., 2009), finding that 13 per cent of the population met diagnostic
criteria for an anxiety disorder during the past seven days. The same survey showed
that 43 to 75 per cent of those with an anxiety disorder received no treatment at all,

Co-morbidity and anxiety disorders

It is commonplace for people to have more than one anxiety disorder at the
same time and for people with anxiety disorders also to be depressed.
Assessment at a large US outpatient clinic showed that 64 per cent of people
with depression attending the clinic also had an anxiety disorder and that 43
FOCUS 7.1

per cent had more than one anxiety disorder (Brown et al., 2001). Anxiety
disorder can also co-occur with severe mental health difficulties like
personality disorder, psychosis, dementia or alcohol and drug misuse. Those
with co-morbid conditions tend to have more severe difficulties and these
may require adaptations to treatment.
 WORKING WITH ANXIETY DISORDERS 115

TABLE 7.1 Common anxiety disorders with key symptoms

Specific phobia • Excessive anxiety triggered by specific objects or situations
(e.g. spiders or flying).

Social anxiety • Excessive fear of being judged negatively by others in social or

disorder performance situations.

Panic disorder • Recurrent unexpected panic attacks (rapidly surging bodily sensations
of anxiety).
• Anxiety about the perceived implications of the attack or its
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consequences (e.g. a concern that a racing heart means that a heart

attack is imminent).

Agoraphobia • Anxiety about and avoidance of being in places or situations

where escape is difficult/embarrassing or where help is unavailable
(e.g. travelling on public transport). Often the core fear is that a panic
attack will occur in these situations.

Generalised • Excessive worry about a variety of everyday events and problems

anxiety disorder (e.g. work, money, relationships).
• Physical tension and difficulty relaxing.

Obsessive • The presence of obsessions, compulsions or both:

compulsive o Obsessions: recurrent and persistent thoughts, impulses or
disorder images experienced as intrusive and inappropriate
(e.g. contamination by germs, harming a loved one).
o Compulsions: repetitive behaviours (e.g. hand washing, ordering,
checking) or mental acts (e.g. praying, counting, repeating words
silently) that the person feels driven to perform (typically
thematically linked to obsessions (e.g. hand washing to avoid
contamination with germs)) and that are aimed at reducing
anxiety.

Post-traumatic • Exposure to a traumatic (often life-threatening) event where the

stress disorder person’s response involves intense fear, helplessness or horror.
• Re-experiencing symptoms (e.g. flashbacks and nightmares).
• Avoidance/numbing symptoms (e.g. trying not to think about what
happened).
• Hyper-arousal symptoms (e.g. difficulty sleeping, very alert to potential
danger).

and of those who did only 2 per cent received CBT, the psychological therapy with
the strongest evidence base for treating anxiety disorders.
Anxiety disorders can begin at any age, with most people developing them between
7 and 31 years old (Kessler et al., 2005). Being female or of low socio-economic status
significantly increases the risk of developing anxiety disorder (Michael et al., 2007).
Table 7.2 shows prevalence of the main disorders during one-week and one-year
periods.
 116 ALESIA MOULTON-PERKINS ET AL.

TABLE 7.2 Prevalence of anxiety disorders

Prevalence (%)
7 days 12 months
UK USA Europe
Specific phobias 8.7 3.5
Social phobia 6.8 1.2
GAD 4.4 3.1 1.0
PTSD 3.0 3.5 0.9
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Panic disorder 1.1 2.7 0.8

All phobias 1.1
OCD 1.1 1.0
Any anxiety disorder 18.1 6.4
Source: McManus et al. (2009); Kessler et al. (2005); Alonso et al. (2004)

AETIOLOGY

Understanding what leads to the onset of anxiety disorders has lagged behind the
development of effective psychological treatments, which usually tackle processes
maintaining the problem rather than attending in detail to its origins. While different
theorists have stressed different factors in aetiology, it is likely that biogenetic
vulnerability, combined with environmental stressors, creates the context for the
development of troublesome anxiety, which may persist and become a disorder
through the interplay of behavioural and cognitive psychological factors.

Biological factors
Anxiety disorders usually occur in the absence of any identifiable biological cause.
However, there appears to be a genetic vulnerability to anxiety disorders. For example,
twin studies show that monozygotic twins, sharing identical genetic make-up, are much
more likely to both develop specific phobia than dizygotic twins (49 per cent
compared to 4 per cent) (Marks, 1987). The processes underlying this are unclear, but
natural variation in anxiety responses within a species is likely to confer an evolutionary
survival advantage.

Environmental factors
Exposure to repeated unpredictable and uncontrollable negative life events, or grow-
ing up in an over-protective, over-controlling family environment, increases risk of
later anxiety disorder compared to sensitive, consistent caregiving (Barlow, 2002).
Some anxiety disorders are clearly triggered by a particular traumatic event or events,
notably PTSD, and sometimes social phobia and specific phobias (e.g. driving phobia
 WORKING WITH ANXIETY DISORDERS 117

after a car accident). However, anxiety disorder also commonly occurs in the absence
of any history of this sort, and many who have experienced such adversity do not go
on to develop anxiety disorder.

Psychological factors

Behavioural theory
Behavioural theory proposes that fears are learned. Three learning processes have been
proposed:
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• Classical conditioning (Watson and Rayner, 1920): where previously neutral

stimuli become feared as a result of being paired with stimuli that induce an anxiety
reaction. For example, if you have a frightening car accident on a particular stretch
of road, you may feel anxious weeks later when you pass that area again.
• Operant conditioning (Mowrer, 1948): where anxious avoidance is said to persist
through negative reinforcement of avoidance behaviours, through the repeated
pairing of avoidance and the relief of anxiety. For example, avoiding the stretch
of road where you had the accident becomes a habit because this means you don’t
get anxious.
• Social learning theory (Bandura, 1977): which proposes that fears can be acquired
vicariously through observational learning. For example, your child may start to
get anxious too when you pass the feared stretch of road, because they see you
are scared.

Behavioural theories of aetiology represent useful explanations of some aspects of

anxiety disorder, and have been influential in the design of some successful treat-
ments.

Cognitive theory
Cognitive theory proposes that people develop anxiety disorders when they
misinterpret the true level of threat or danger associated with particular stimuli (Beck
et al., 1985; Clark and Beck, 2010). The phenomenon of the overestimation of threat
has been robustly tested experimentally and is a feature of persistent anxiety disorder.
Reversal of these misperceptions of threat has become a focus of successful treatment
across anxiety disorders.
Cognitive-behavioural theory proposes that anxiety disorders arise as a result of a
complex interplay of cognitive and behavioural factors. For example, someone who
has had a car accident may develop a belief that driving along a certain stretch of road
will have catastrophic consequences, and therefore avoid it. The avoidant behaviour
is negatively reinforced, their negative predictions remain intact, habituation is
prevented and therefore subsequent presentation with the feared stimulus evokes
intense anxious arousal.
 118 ALESIA MOULTON-PERKINS ET AL.

THEORY AND EVIDENCE FOR PSYCHOLOGICAL INTERVENTION

Therapies based on cognitive or behavioural principles are effective in treating anxiety

disorders according to evidenced-based guidelines (e.g. National Institute of Clinical
Excellence (NICE), 2004; see also Focus 2.1). Each anxiety disorder has one or more
recognised specific cognitive-behavioural treatments with good evidence of effective-
ness. Therapy is typically brief (2 to 16 hours), collaborative and structured around
reversing key behavioural or cognitive maintaining processes associated with the
particular anxiety disorder(s) being treated. Left untreated, anxiety disorders often
persist, but with psychological therapy between 50 and 85 per cent of people
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completely recover (Roth and Fonagy, 2005).

Behaviourally based exposure therapies

Exposure therapies are based on learning theory, and focus on prolonged and deliberate
exposure to feared stimuli. The therapist guides the person to place themselves into
the feared situation and through a process of habituation anxiety gradually drops. As
a consequence the feared stimulus becomes paired with lack of fear so that ‘extinction’
of the fear is achieved. Exposure therapy is often used with specific phobias, PTSD
and OCD. For example, in PTSD prolonged exposure to the detail of traumatic
memories has been shown to reduce their impact (Foa et al., 2007).

Cognitive-behavioural therapy (CBT)

CBT extends behavioural therapy by additionally tackling the cognitions that drive
anxiety (as illustrated by the detailed case study later in this chapter). Cognitive theory
suggests that anxiety is maintained when people perceive things to be more threaten-
ing than they objectively are. If we think it is very likely that bad things will happen,
or very awful if they do, then we will feel more anxious. However, if we think that
we will be able to cope, or that at least somebody or something may help us, then
our anxiety will be lower. Beck et al. (1985) summarised these ideas in the anxiety
equation:

Perceived probability of threat ×

Perceived cost/awfulness of danger
Degree of anxiety = –––––––––––––––––––––––––––––––––––
Perceived ability to cope with the danger +
Perceived rescue factors

CBT for anxiety disorders aims to strengthen coping appraisals and weaken threat
appraisals, in other words making the denominator larger than the numerator. This is
done by reversing key maintaining cognitive and behavioural processes. For example,
someone with panic disorder may avoid supermarkets fearing an attack, but because
they need to buy food for dinner they are forced to enter the supermarket. Standing
in the check-out queue they experience a slight dizzy feeling (the normal result of
fight-flight physiology). Failing to understand that fainting is not caused by panic,1 they
catastrophically misinterpret their physical symptoms as evidence of imminent collapse.
 WORKING WITH ANXIETY DISORDERS 119

They employ the ‘safety behaviour’ of stiffening their legs. Ironically this makes their
legs even shakier, which raises their anxiety still further. They do not faint, and the
panic gradually subsides, with the catastrophic misinterpretation intact: ‘Thank
goodness I tensed my legs, otherwise I really would have collapsed!’
CBT breaks the vicious cycle by reversing these processes: challenging exaggerated
threat appraisals, teaching approach rather than avoidance, and dropping safety
behaviours. The therapist helps the individual look objectively at how likely and how
awful their feared catastrophe would be, evaluating and challenging cognitive distor-
tions (see Focus 7.2). In order to gather more objective evidence, the patient is taught
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to attend to both positive and negative stimuli, rather than only ‘looking for trouble’
(thus reducing the anxiety equation numerator). Perception of coping ability and access
to rescue factors is increased by a similar process of rational examination of the
evidence, and thus their self-efficacy and perceived sense of control is improved
(denominator thereby increasing). Alongside this cognitive restructuring process, the
individual is assisted to approach the things they are afraid of and have been avoiding.
This may be through conducting behavioural experiments, where they test out their
anxious predictions by dropping safety-seeking behaviours, or by progressing through

Cognitive distortions
Burns (1999) proposed that certain unhelpful thinking styles or ‘cognitive
distortions’ cause us to look at the world through distorted lenses, and
therefore not see things as they actually are but as we fear them to be. While
originally developed for depression (see Chapter 6), several are particularly
relevant to anxiety:

• Jumping to conclusions: (a) Mind reading – you assume that people are
reacting negatively to you when there’s a lack of evidence for this. ‘The
people at the party will think I’m boring and reject me’ (social anxiety);
(b) Fortune-telling – you arbitrarily predict that things will turn out badly.
‘If I get on a bus I won’t be able to cope and I’ll humiliate myself by having
a panic attack and losing control of my bladder’ (panic and agoraphobia).
• Magnification or minimisation: You blow things way out of proportion or
you shrink their importance inappropriately. ‘Touching this toilet seat
means I will be contaminated by a life-threatening illness’ (OCD).
• Emotional reasoning: You reason from how you feel: ‘I feel terrified when
I see this spider, so it must be dangerous’ (specific phobia).
• ’Should’ statements: You criticise yourself or other people with ‘shoulds’
FOCUS 7.2

or ‘shouldn’ts’. ‘Musts’, ‘oughts’ and ‘have-tos’ are similar offenders.

‘Strong men should control their minds and eradicate worries’ (GAD).
• Labelling: You identify with your shortcomings. Instead of saying, ‘I had a
serious attack and many people would be frightened after that’, you say,
‘I’m pathetic and weak because I can’t get over this’ (PTSD).
 120 ALESIA MOULTON-PERKINS ET AL.

exposure and habituation. These exposures may be ‘in vivo’ (direct or live) or
‘imaginal’ (indirect or imagined). Facing the feared situation and discovering that no
catastrophe occurs provides further evidence to erode the original exaggerated threat
appraisal, thus reducing anxiety and physiological arousal.

Eye movement desensitisation and reprocessing

This approach to treatment originated with a chance observation by Shapiro (1995)
who observed that moving her eyes from side to side repeatedly while reviewing
distressing memories appeared to lead to relief from distress. A short-term treat-
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ment (typically 8 to 18 hours) was developed and trialled for PTSD based on
reviewing trauma memories and meanings while making these eye movements,
tracking movements of the therapist’s fingers. This treatment has proved as effective
as trauma-focused CBT for the treatment of PTSD, although the active ingredients
of the treatment remain a subject of debate and investigation (e.g. van den Hout and
Engelhard, 2012).

CASE STUDY

Jim was a 54-year-old man who went to see his GP because he had become very
anxious and depressed. He was unable to shake off worries about several topics,
including family relationships, housing and health issues. Jim’s GP used some
questionnaire measures which showed that he was experiencing severe anxiety and
moderately severe depressive symptoms. Antidepressant medication was proving
ineffective and she decided to refer Jim to the local Primary Care Mental Health
Team. Jim met with a clinical psychologist, Theresa.

Assessment
At the first session, Jim described various recent negative life events starting two
years previously with a stressful time in his job as a senior accountant. Following this
he started to feel depressed and anxious. He also injured his back, and after
developing mobility difficulties was medically retired. His wife left him, and their
teenage daughter reacted badly by avoiding school work, consequently failing an
important exam.
Jim told Theresa that he had always been ‘a worrier’, but had never been
depressed before. Since the separation he had felt especially low, withdrawing from
socialising and finding decision making tortuous as he over-analysed and worried
over every eventuality: his health and whether he should manage his mobility
problems by moving to a bungalow or building a downstairs extension, how to repair
the relationship with his wife, how to occupy his time now that he was retired, and
how to encourage his daughter to start studying for her exam resits. He felt unable to
stop these worry bouts, fearing they would send him mad or damage his health. All
this worrying left him exhausted and depressed.
 WORKING WITH ANXIETY DISORDERS 121

Theresa suspected that Jim had developed generalised anxiety disorder (GAD)
and investigated this further by asking him to complete the Penn State Worry
Questionnaire (PSWQ). This is a validated 16-item measure of trait worry. Jim scored
63/80, clearly above the cut-off score for GAD of 45.

Formulation
Theresa and Jim worked together to come to a shared understanding of how his
problems began and were then maintained.
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How the problems developed

• Predisposing factors: Theresa made use of Judy Beck’s (Beck, 1995)
developmental CBT model, which highlights how early life experiences can lead to
particular negative beliefs, assumptions and unhelpful coping strategies. Relevant
aspects of Jim’s early life included an unaffectionate father who only praised him
when he achieved perfect performance at school, and an anxious mother who
saw potential disaster everywhere. Jim developed beliefs about himself as
unlovable, others as critical, and the world as a difficult and dangerous place.
He lived according to certain rules and assumptions such as ‘If I excel in
everything, I’ll be a worthwhile person’ and ‘I must foresee and prepare for all
potential problems’. As long as he could follow his rules and use his preferred
coping strategies like overworking, appeasing others or over-analysing decisions
he felt in control and OK.
• Precipitating factors: A series of negative events around Jim’s job, health,
marriage and daughter pitched his life into chaos. Jim’s normal coping strategies
did not work and he struggled to maintain control. His difficulty in tolerating the
unknown and failure to meet his expectations of himself as a man meant he
judged himself cruelly for not coping and therefore he tried even harder to solve
his problems by analysing every eventuality. Incessant worry about work, and his
failing marriage, led to chronic generalised anxiety and depression.

How the problems were maintained

Theresa and Jim drew a diagram based on Dugas and Robichaud’s (2007) GAD
model. This diagram was built up in stages over a series of sessions to explain how
specific cognitive and behavioural factors were maintaining his worry and eventually
leading him to become demoralised, exhausted and depressed. Maintaining factors
in the model include the following:

• Intolerance of uncertainty: Jim was clearly intolerant of uncertainty as a result of

his early experiences and was always grappling to arrive at a perfect conclusion to
his concerns.
• Beliefs about worry being a helpful strategy: Jim described a number of ‘positive’
beliefs about worry, including ‘worrying helps me to problem solve and prove I’m
a good parent’.
 122 ALESIA MOULTON-PERKINS ET AL.

• Negative orientation to problem solving: Jim tended to catastrophise when faced

with a decision, and increasingly doubted his problem-solving abilities.
• Cognitive avoidance: Jim avoided thinking about the real losses he had suffered
over recent months, inhibiting emotional processing and further maintaining his
anxiety.

These factors together led to persistent worry processes. He tended to pose himself
a series of ‘what if?’ questions: ‘What if my wife meets someone else . . . my
daughter fails her resits . . . my back gets worse . . . the builders I choose to build
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my house extension swindle me?’

Jim ceased pursuing previously enjoyed sports like bowls and avoided friends. He
became depressed which in turn maintained his anxiety further because inactivity left
more time for worry, and more things to worry about. He started to ‘worry about
worry’, thinking his anxiety could further damage his health.
The final diagram, which shows the main factors maintaining GAD, illustrated by
the way this specifically applied to Jim, in his own words, is shown in Figure 7.1.

Action plan
Theresa offered Jim 16 sessions of CBT in line with NICE (2004) guidelines. Theresa
explained that the therapy would follow the formulation they had made together, and
they agreed the following aims:

1 To help decrease Jim’s worry by increasing tolerance of uncertainty, re-evaluating

the usefulness of worry, and enhancing problem-solving ability.
2 To reduce depressive symptoms by problem-solving difficulties with interpersonal
relationships and increasing activities likely to improve Jim’s mood.

Jim identified specific goals, including the following:

• Reducing stress and anger with his daughter around her lack of studying by letting
go of worries about this.
• Making decisions more easily, reducing stress levels so that he could enjoy his
retirement more.
• In the longer term finding greater acceptance of his health problems and changed
professional identity and status.

Intervention
Decreasing Jim’s worry
Theresa introduced various cognitive and behavioural methods to target each of the
main maintenance factors from the formulation:

• Using exposure to increase tolerance of uncertainty: Jim and Theresa made a list
of situations he was facing involving uncertainty, especially those requiring a
decision, and their potential to trigger worry bouts was related to the formulation.
 WORKING WITH ANXIETY DISORDERS 123

Situation
Daughter avoiding school work. Separation. Building extension.

Intolerance of uncertainty Intolerance of uncertainty

Intolerance of uncertainty What if ...Intolerance
? of uncertainty
Intolerance of uncertainty Intolerance of uncertainty
... my daughter fails her re-sits? ... my wife starts a relationship with
Intolerance ofsomeone
uncertainty Intolerance
else? ... my builder swindles me? of ... uncertainty

Intolerance of uncertainty Intolerance of uncertainty

Intolerance of uncertainty Intolerance of uncertainty
Intolerance of uncertainty Intolerance of uncertainty
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Intolerance of uncertainty Intolerance of uncertainty

Positive beliefs about worry
‘Worrying helps me to solve problems and shows I am
Intolerance of uncertainty Intolerance of uncertainty
a good parent’
Intolerance of uncertainty Intolerance of uncertainty

Life events
Mood

Intolerance of uncertaintyWORRYIntolerance of uncertainty

Intolerance of uncertainty Intolerance of uncertainty
Intolerance of uncertainty Intolerance of uncertainty
Intolerance
orientation of uncertainty
Negative problem
Intolerance of uncertainty
Cognitive avoidance

Intolerance
‘I can’t of uncertainty
cope, even making ANXIETY Intolerance ofcounting uncertainty
Thought suppression and
to 10 when
Intolerance of
decisions is impossible!
I’ll have a breakdown’
uncertainty Intolerance of uncertainty
anxious

Intolerance of uncertainty Intolerance of uncertainty

Intolerance of uncertainty Intolerance of uncertainty

Demoralisation/Exhaustion
Back ache worse. Given up
bowls club and seeing friends

DEPRESSION

FIGURE 7.1 GAD maintenance model

Source: Based on Dugas and Robichaud (2007).

For example, Jim was worrying about building a house extension, becoming
increasingly anxious as he tried to choose between various designs and
builders. He imagined cowboy builders swindling him and leaving a crumbling
wreck. ‘Fortune-telling/catastrophisation’ and ‘magnification/minimisation’
cognitive distortions trapped him in a never-ending chain of ‘what-ifs’ which
paralysed his decision-making ability. He was encouraged to face the
uncertainty of whether his chosen builder would be perfect by dropping his
usual safety behaviour of over-planning and instead make a timely decision.
The builder was chosen and the work completed, not perfectly but adequately.
 124 ALESIA MOULTON-PERKINS ET AL.

Jim learned that he could tolerate the uncertainty and tension, and that, even
when things do not turn out perfectly, he could cope.
• Cognitively restructuring beliefs about worry being helpful: Theresa asked Jim
to think of his ‘positive’ beliefs about worry when they were discussing his
concerns about his daughter’s lack of studying. Theresa and Jim explored the
effect of Jim’s worry upon his relationship with his daughter. Jim realised that
worry had led him to become over-controlling, much as his father had been
with him. Rather than work harder as Jim had done as a boy, his daughter had
become defiant and less studious. Jim finally accepted that he could not
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‘make’ his daughter work, and that it was indeed uncertain whether she would
pass her resits. Jim started to ‘let go’ a little of his worries and instead focused
more on engaging in fun activities with her. Thus, Jim was able to re-evaluate
the usefulness of his beliefs that worrying assists problem solving and
demonstrates good parenting.
• Helping Jim to have a more positive orientation to problem solving: Theresa and
Jim discussed the difference between hypothetical problems (‘what if . . .’) and
real current problems. Real current problems demanded a problem-solving
approach whereas hypothetical worries required an acceptance-based approach.
In order to raise his awareness of these two types of worries Jim agreed to
complete a worry diary for homework. Theresa then introduced Jim to a
structured method of problem solving for real current problems, and acceptance-
based techniques for hypothetical worries.
• Using exposure to address cognitive avoidance: Several sessions into the therapy,
Jim told Theresa that he had been avoiding anxious and painful feelings by trying
to think about other things (thought suppression) and counting to ten to distract
himself (a safety behaviour). He feared that not doing these things would
eventually lead to a breakdown. Theresa asked Jim to picture the scene he
dreaded most: his wife walking along hand in hand with another man. While doing
this ‘imaginal exposure’ he was invited to drop his safety behaviours, and instead
allow himself to feel and think whatever came to mind. Jim became initially very
upset, but as he emotionally processed and habituated to these core fears he
gradually calmed down.

These interventions collectively helped Jim realise that his anxious thinking styles
had distorted reality: exaggerating threats and underestimating his coping ability.

Decreasing Jim’s depression

• Challenging cognitive distortions and behavioural avoidance: As treatment
progressed and Jim’s anxiety reduced, there was an increasing emphasis on
overcoming depression and identifying his interpersonal needs. His wife’s
departure had triggered painful beliefs about worthlessness. These beliefs were
identified and then re-examined, allowing him to arrive at a more balanced view.
Planning pleasurable activities like visiting friends, and re-engaging in gentle
physical exercise like playing bowls, helped Jim manage his low mood.
 WORKING WITH ANXIETY DISORDERS 125

Towards the end of therapy a relapse prevention plan was collaboratively

constructed. Triggers and early warning signs of relapse for worry and low mood
were identified and an action plan was outlined.

Outcome
Jim made good progress in reducing his worry and depression, as his scores on
questionnaire measures testified. His emotional resilience and perception of coping
skills increased. Jim’s belief in the usefulness of worry decreased and he was more
confident in solving problems in more effective ways. His greatest worry had been
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that if his wife started a relationship with another man, he would break down into
severe depression. Towards the end of therapy he discovered that she had indeed
started a new relationship. Instead of having a breakdown, he was understandably
upset but found he was able to cope.
Jim’s relationship with his daughter improved as he ceased to allow worries about
her studying to dominate. Jim started meeting up with friends and engaging in sport
once more. He began to enjoy his retirement, and achieved greater peace and
acceptance over his changed health and professional status.

TEAM WORKING/INDIRECT WORK

Clients with problems like Jim’s are generally seen in settings where most of the work
is direct and conducted by a single professional (clinical psychologist or psychological
therapist) at any one time. However, with severe and enduring anxiety disorders (e.g.
if house-bound or self-neglecting) or where there are significant co-morbid mental
health difficulties, such as psychosis, personality disorder or severe depression, a multi-
disciplinary team approach is likely to be helpful. The work of clinical psychologists
in these multi-disciplinary settings tends to include a range of indirect work, such as
the following:

• Supervision of multi-professional colleagues: For example, a psychologist may be

seeing a client with severe agoraphobia for CBT, but also supervising a support
worker who visits the client in the community, providing practical assistance with
completing exposure tasks, such as travelling on public transport.
• Providing in-house training to non-psychologist colleagues: This could, for example, cover
the use of manualised psychological interventions, such as psycho-educational
anxiety management groups.

CRITICAL ISSUES

Low- and high-intensity treatments

There has been much interest in ‘low-intensity’ interventions for anxiety disorders and
depression. These tend to be based on very brief contact with practitioners who are
 126 ALESIA MOULTON-PERKINS ET AL.

not trained as therapists but who support the use of online or paper-based self-help
materials (Clark et al., 2009). These therapies are distinguished from ‘high-intensity’
CBT or other psychological therapies. Some low-intensity therapies have been found
to be just as effective as their high-intensity equivalents. For example, an internet-
delivered cognitive therapy for social anxiety disorder succeeded in achieving
comparable results to face-to-face therapy in one-fifth of the time (Stott et al., 2013).
Low-intensity treatments are of interest because they can allow greater numbers of
people to be treated for the same cost, and have shown some promising results
compared to no-therapy control groups. However, in most cases it is not known how
the effectiveness of low-intensity and high-intensity treatments compare. The ‘high-
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intensity’ individual therapy format therefore remains the treatment of choice for most
people with more persistent anxiety disorders.

Trans-diagnostic treatments
Specific CBT treatments have been developed to tackle certain maintaining factors
for each of the main anxiety disorders, resulting in a number of distinct treatments for
different disorders. Each one has been evaluated and therapists are trained to deliver
it. However, having lots of different specialist treatments presents some problems. First,
it is very common to have more than one type of problem and the specific treatments
are less clear about how this should be tackled. Second, it means that therapists need
to learn and stay skilled at many different forms of treatment, which can be difficult
if they are only using each one infrequently. There is growing interest in ‘trans-
diagnostic’ treatments for anxiety or mood disorders, which may help to tackle these
issues. Trans-diagnostic approaches are based on a set of modules of therapy, each
designed to tackle a problem that occurs across several different conditions (e.g. avoid-
ance). Modules may then be chosen and joined together to tailor the therapy to
individual need (e.g. Barlow et al., 2010). There are some promising early results, but
the effectiveness of trans-diagnostic treatments is still relatively unknown (Farchione
et al., 2012).

MILLIE’S STORY: THE CONCLUSION

I went to Occupational Health at the hospital and was referred to a clinical psychologist
for ten sessions of cognitive-behavioural therapy. During our sessions we discussed
situations that arose regularly for me and came up with ways of overcoming them.
We set goals, sometimes pushing me to do things I never believed possible. I actually
spoke to the OCD in my head, telling it to leave me alone. I had to stop myself wetting
my fingers, which sometimes seemed almost impossible. I knew I was winning when
I made myself touch my fingers on the floor and not wipe them. It felt good. My
psychologist taught me that I was allowed to be in control. I do have days when it
controls me but they don’t last. On these days I remember those sessions, think what
we did at the time and get back on track.
 WORKING WITH ANXIETY DISORDERS 127

KEY CONCEPTS AND TERMS

• Post-traumatic stress • Generalised anxiety • Fight-or-flight

disorder disorder response
• Panic disorder • Social anxiety • Classical conditioning
• Agoraphobia disorder • Operant conditioning
• Specific phobia • Exposure therapy • Eye movement
• Obsessive • Graded hierarchy desensitisation and
compulsive • Worry reprocessing
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disorder • CBT

LEARNING OUTCOMES

When you have completed this chapter you should be able to:

1 Know what features or symptoms are characteristic of the anxiety disorders.

2 Understand the psychological impact of the anxiety disorders.
3 Understand the psychological theories or models that are relevant to the anxiety
disorders.
4 Understand the treatment approaches used by clinical psychologists, and the
evidence base for these approaches.
5 Understand how assessment, formulation, intervention and evaluation may be
used by a psychologist working on a specific case.

SAMPLE ESSAY TITLES

• What are the key maintaining factors across anxiety disorders and what strategies
are helpful in their treatment?
• Describe the main theories of how anxiety disorders develop. What are their relative
strengths and limitations?
• Describe the phenomenology, aetiology and epidemiology of two common anxiety
disorders.
• How can psychologists work individually and in teams to help people with anxiety
disorders?

NOTE

1 Blood pressure rises with panic/anxiety. Fainting is associated with low blood pressure.
The only anxiety disorder associated with fainting is blood injury phobia when blood
pressure drops suddenly.
 128 ALESIA MOULTON-PERKINS ET AL.

FURTHER READING
Davey, G.C., Cavanagh, K., Jones, F., Turner, L. and Whittington, A. (2012). Managing Anxiety
with CBT for Dummies. New York: John Wiley & Sons.
Wells, A. (2013). Cognitive Therapy of Anxiety Disorders: A practice manual and conceptual guide.
New York: John Wiley & Sons.

REFERENCES
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Alonso, J., Angermeyer, M.C., Bernert, S., Bruffaerts, R., Brugha, T.S., Bryson, H. and
Vollebergh, W.A.M. (2004). Prevalence of mental disorders in Europe: Results from the
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Bandura, A. (1977). Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall.
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Barlow, D.H., Farchione, T.J., Fairholme, C.P., Ellard, K.K., Boisseau, C.L., Allen, L.B. and
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 8 Working with people
with psychosis
Mark Hayward, Sara Meddings
and Jo Harris
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JO’S STORY

Looking back, I had a lot of factors that contributed to my psychosis. I was a quiet
child, lacking in confidence. My parents divorced when I was 8 years old and my
father was treated for depression so it seems to run in the family. My father was a
disinterested one, reinforcing my feelings of worthlessness.
I found it hard at secondary school to make friends and not having a lot of money
meant I was singled out. While it wasn’t physical, mainly name calling and being spat
at, it reinforced the feeling that I didn’t deserve to be here. By now I was hearing
‘inside’ voices in my head telling me I was useless, shouting words like ‘Bitch!’ and
‘Die!’ I was having severe mood swings. I thought about self-harming and became
controlling about my food intake. At age 14 I started taking drugs and drinking
alcohol. Between 14 and 21 I had a cannabis and cocaine addiction which I
overcame. At age 24 I was planning my suicide when my father died. Within three
days I was having extreme audio and visual hallucinations such as whispering and
people calling my name and seeing deceased people, dead bodies and shadows as
well as everyday objects. People also transformed into other people in front of me,
leading me to believe they were possessed by the dead. I also heard menacing
voices issuing commands. I experienced strange smells, tasting poison in my food
and on one occasion felt someone stroking my hair. I thought that my mind was
being controlled, that I could communicate with the dead and that, because of this,
the government was spying on me and plotting to kill me.
 WORKING WITH PSYCHOSIS 131

SUMMARY

What is it like to experience the range of distressing experiences that Jo describes in her
story? Hearing a voice criticising you and calling you names; believing other people are
controlling you; having few friendships; using alcohol and street drugs to control your
feelings; and to feel so hopeless about the future that you want to die? These are common
experiences of people who struggle with psychosis. We will draw upon our personal, clinical
and academic experience to offer insights into how clinical psychologists understand these
experiences and work alongside people experiencing psychosis to alleviate distress, build
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hope and enhance quality of life. We have chosen to focus upon psychotic experiences
and associated problems, rather than confine their exploration to any particular diagnosis.
However, the value of diagnosis is acknowledged, as is the dominance of the diagnostic
category of schizophrenia when considering psychotic experiences.

WHAT ARE THE TYPES OF PSYCHOLOGICAL DIFFICULTIES

THAT CAN OCCUR WITH PSYCHOSIS?

People with psychosis make up the largest group of people with serious mental health
problems seen by secondary mental health services in the UK National Health Service.
Psychosis refers to a range of unusual or frightening experiences often associated with
a detachment from reality, such as paranoia or hearing voices. People who experience
psychosis face many of the same life and psychological challenges as anyone else. They
also have the same range of aspirations – getting a job, having a decent life with friends
and family, somewhere to live. Their main psychological challenges may be about how
to live a meaningful life with a positive self-identity, while their unusual and frightening
experiences continue. They also experience above-average levels of depression, trauma
and anxiety, and some people experience significant highs and lows of mood.
The kinds of challenges faced by people with psychosis relate both to the psychosis
itself as well as to pre-existing challenges and traumas which may have made the person
more vulnerable to the psychosis initially and the psychological and social challenges
resulting from and possibly maintaining the psychosis.
Distressing psychotic experiences include the following:

• Hearing voices, seeing visions, tasting, feeling or smelling things which other people do
not hear, see, taste, feel or smell. These are sometimes described as ‘hallucinations’
and are experienced as real. For example, Pete heard the voice of a man telling him
‘you are dirty – you are worthless’ and felt the sensation of insects crawling over his
body. Jane heard a voice saying ‘Jane is a useless mother, her daughter hates her’.
Often these voices seem all-knowing and all-powerful and may relate to a person’s
previous experiences or to worries they may have. Some people view voices and
visions as a spiritual gift – the experiences are more likely to be seen as psychosis
when outside of cultural norms and when they are distressing and disabling.
• Holding strong beliefs which other people do not share. For example, Pete used to
feel paranoid that a researcher was filming him and was going to harm him. John
thought that he was a top spy working for MI5. Where such thoughts are about
 132 MARK HAYWARD ET AL.

other people trying to hurt you they are sometimes described as ‘paranoid delu-
sions’, and where they are about being special as ‘grandiose delusions’. Delusional
beliefs and voice hearing are sometimes described as ‘positive symptoms’, as they
are experiences that are additional to usual functioning – not because they are
enjoyable!
• Cognitive difficulties with thinking or concentrating. These may include making unusual
connections between ideas or talking in ways that other people cannot follow –
sometimes referred to as ‘thought disorder’. People may also have difficulties with
remembering and learning; with being easily distracted; and with executive
functioning about planning and problem solving. They may struggle to motivate
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themselves, withdraw from social activity and feel emotionally flat. Some but not
all of these difficulties may be partially attributed to the challenges of coping with
the delusional beliefs and voices. For example, Greg hears voices and finds it hard
to concentrate – he copes by withdrawing into his bedroom and not going out
very much. He easily forgets appointments and so likes someone to text him to
remind him. These difficulties are sometimes described as negative symptoms, as
they represent a loss of usual functioning.
• Psychological difficulties. Stresses and challenges in life such as abuse and trauma
increase vulnerability to psychosis or may lead to psychosis. Making sense of and
dealing with these challenges aids recovery from the psychosis itself. Depression,
trauma, social anxiety, insomnia, low self-esteem and social withdrawal may result
from life challenges or from the psychosis. Often they precede and exacerbate the
psychosis in a vicious maintaining cycle. Psychosis is also associated with a number
of losses, including loss of your idea about who you are, loss of meaning in life,
loss of control (often exacerbated by stigma and disempowering effects of services),
and loss of hope for the future. Parallel losses may also be experienced by the
person’s relatives. People often need to grieve for and work on acceptance of these
losses as part of moving on in order to take back control and find hope.
• Social and practical difficulties. People with psychosis may be more likely than other
groups of people to have small social networks and be unemployed – both because
of the psychotic symptoms themselves and also pre-existing social anxiety which
may be exacerbated after diagnosis by reduced expectations and workplace
discrimination.
• Physical health problems. People with psychosis also experience increased physical
health problems such as diabetes and have a life expectancy of 15 years less than
the general population.
• Safety issues. Issues of safety are also a challenge for people with psychosis and those
around them. People with psychosis are not at a higher risk than the general
population of committing violence against other people, contrary to popular
perceptions often conveyed in the media. However, people with psychosis are
more likely than others to be victims of violence. They are also more likely than
others to kill themselves – suicide is especially related to being unemployed,
concurrent physical health problems, feelings of hopelessness and the availability
of methods of suicide.

For further reading about the issues discussed in this section see the British
Psychological Society (2014) and Repper and Perkins (2003).
 WORKING WITH PSYCHOSIS 133

DIAGNOSIS

Psychosis is associated with a number of diagnoses which have historically been

grouped together and differentiated from mood disorders. Psychotic experiences are
a key feature of a number of diagnoses within DSM-V (APA, 2013), including the
following:

• Schizophrenia – characterised by significant distortions of thinking and perception,

and inappropriate or blunted emotions.
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• Schizoaffective disorder – characterised by prominent psychotic experiences and

less prominent disturbance of mood, and for which a diagnosis of schizophrenia
or a mood disorder is not justified.
• Bipolar affective disorder – characterised by significant disturbance of affect and
activity levels. Episodes of elevated mood and increased energy and activity occur
intermittently, as do contrasting episodes of low mood and decreased energy and
activity.
• Severe depression with psychotic symptoms – characterised by lowering of mood,
reduced self-esteem, ideas of worthlessness or guilt, and delusions and hallucin-
ations.

Note: Schizophrenia and schizoaffective disorder are part of a broader classification of schizo-
phrenia spectrum disorders. Psychosis with organic origins is seen as separate from the above
categories.

This chapter focuses on psychotic experiences rather than on the diagnostic groups or
the mood difficulties that often go with psychosis (especially with psychotic depression,
bipolar affective disorder, schizoaffective disorder and severe depression). The scientific
validity of separable diagnoses has been questioned (Bentall, 2003) on a number of
grounds:

• The symptoms may be understood in the context of life challenges not requiring
a disease explanation and which are seen on a continuum.
• There is no common aetiology for a specific diagnosis and overlap between
different ones.
• There is no evidence of specific genetic disease markers.
• Clinically there is often disagreement between clinicians about an individual’s
diagnosis.

It may therefore be preferable to focus on the symptoms, behaviours and experiences

which people have rather than broad classifications. Effective treatments seem to relate
to these or to the broader spectrum of psychosis as a whole and not to specific
diagnostic groups. Nevertheless, diagnosis can be a useful shorthand, and some of the
research we cite in this chapter relates to specific diagnostic categories.
 134 MARK HAYWARD ET AL.

EPIDEMIOLOGY

About 1 per cent (0.5 to 2%) of the general population will be diagnosed with
schizophrenia spectrum or bipolar disorders at any time and the lifetime prevalence
for psychosis is 3 per cent (van Os et al, 2009; Schizophrenia Commission, 2012; NICE,
2014). Rates are similar worldwide. However, there is a continuum of experience:
about 15 per cent of the general population sometimes hear voices (Tien, 1991), and
15 to 20 per cent have regular paranoid thoughts (Freeman and Garety, 2006).
Psychosis can develop at any age, but most commonly starts in adolescence and young
adulthood.
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AETIOLOGY

Biological, psychological, social and environmental factors all contribute to vulnerability

towards and resilience against the onset and maintenance of psychosis. One way of
understanding how these factors interrelate is through a stress vulnerability model
(Zubin and Spring, 1977). Early life experiences, current environment and biological
factors can make people more vulnerable to psychosis when faced with stresses. People
who are particularly vulnerable for any of these reasons may experience psychosis after
a relatively minor stress (point ‘c’ in Figure 8.1). Even the most resilient of people

ILL
STRESS

WELL

VULNERABILITY

FIGURE 8.1 The stress–vulnerability model of mental illness and well-being

Source: From Zubin and Spring (1977). Copyright © American Psychological Association.
 WORKING WITH PSYCHOSIS 135

could experience psychosis if subjected to the highest levels of stress (point ‘a’ in Figure
8.1) (see Kingdon and Turkington (1994) for a review of the associations between
stress and ‘normal’ circumstances in which psychotic experiences may occur).

Biological factors
Neuro-chemical imbalances in the brain increase the likelihood of someone developing
psychosis. This is most notable in terms of the impact of cannabis use which can be
predictive of psychosis for some people – particularly if they have a predisposing
vulnerability (Henquet et al., 2004). Brain studies show that neuro-transmitters such
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as dopamine seem to act differently in people with psychosis. Medication which targets
such chemical pathways does lead to improvement for some people. In recent years
there has been significant criticism of earlier twin and adoption studies of the genetic
basis of psychosis. Nevertheless, there does seem to be a genetic component which
may make some people more vulnerable to experiencing psychosis (see Bentall (2003)
for a review of the debates about biological factors).

Psychological factors
Self-esteem
Low self-esteem (feelings of limited worth and value) may play a causal and maintaining
role in a range of mental health problems, including psychotic experiences (Garety
et al., 2001). This cognitive vulnerability is characterised by negative beliefs about who
one is as a person (e.g. ‘I am weak/stupid/unlovable’). These beliefs seem true, generate
high levels of emotional distress and are often long-standing due to their roots in early
experiences of social adversity and trauma. Low self-esteem may also be a product of
an individual’s experience of psychosis and its negative social context, including
hospitalisation and exposure to prejudice.
Information processing
Biases in information processing also play a key role in the maintenance of psychotic
experiences – particularly paranoid beliefs.
People with paranoid beliefs have a ‘jumping to conclusions’ reasoning style that
leads them to make quick decisions based on limited information (Garety and Freeman,
1999). This makes sense in relation to our survival instinct. If I am in a situation where
I feel suspicious and unsafe, it is logical for me to make a quick decision about the
intentions of other people if someone behaves towards me in a way that could be
interpreted as threatening. Of course, I could be wrong about those intentions – but
if I am right I get a chance to escape. The fact that I feel threatened when entering a
situation may lead me to conclude that I am under threat – ‘emotional reasoning’. But
these feelings are likely to result from my expectations which set up a vicious cycle.
Within this scenario the confirmatory bias is also likely to play a role - environmental
information that is consistent with and confirms existing beliefs is noticed preferentially,
whereas disconfirmatory information is filtered out and essentially ignored. In the
scenario described above, I will be hyper-vigilant for and notice the (possibly)
threatening behaviour of others, but will pay little or no attention to the behaviour
of people which suggests otherwise.
 136 MARK HAYWARD ET AL.

Social and environmental factors

The majority of people who come into contact with mental health services due to
psychosis have experienced some form of abuse or trauma in childhood or adolescence.
Sixty-nine per cent of women and 59 per cent of men with psychosis have been
physically or sexually abused as children and over half as adults (Read et al., 2005).
People with psychosis have typically experienced higher than average levels of
childhood social deprivation, social isolation and other forms of social exclusion (Bentall
et al., 2012). Unemployment, poverty in adulthood and inequality and relative
deprivation also make people more vulnerable to psychosis. Recovery rates are better
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during periods of full employment than of economic recession and in developing

countries than in industrialised ones (Warner, 1994), perhaps due to closer family
cohesion, work opportunities and social inclusion. Being valued by others, having
control over one’s own life, and work, family and community relationships are
important (Tew et al., 2012).

The above review of aetiology suggests that a full understanding of the variables that
may influence the cause and maintanence of psychosis needs to embrace a holistic
biological, psychological and social approach – a bio-psychosocial approach. The
formulation shown in Figure 8.2 uses a bio-psychosocial approach to understand Jo’s
experiences.

PROGNOSIS

About half of people who have psychosis and might be diagnosed with schizophrenia
spectrum disorder have only one episode and then recover completely. About a quarter
have ongoing symptoms and a quarter have a fluctuating condition with periods of
wellness and illness.
However, prognosis may be considered in a broader sense, not just in terms of
symptoms. People with psychosis have a wide variety of needs and priorities for
recovery. They may want to focus upon reducing symptoms, or upon improving
relationships, confidence or getting a job. Therefore practitioners need to focus upon
those outcomes which an individual sees as important – their personal goals. ‘Recovery
is about building a meaningful and satisfying life, as defined by the person themselves,
whether or not there are ongoing or recurring symptoms or problems’ (Shepherd
et al., 2008). Many people with psychosis live full and meaningful lives.

USE OF THEORY AND EVIDENCE IN PSYCHOLOGICAL

PRACTICE

There is evidence for the efficacy of cognitive-behavioural therapy and family

interventions for psychosis as well as anti-psychotic medication and employment
interventions – all are recommended by the National Institute of Health and Clinical
Excellence (NICE, 2014).
 Biological vulnerability
e.g. father treated for depression,
possible bipolar symptoms

Vulnerability from
Protective factors [CAUSAL life experiences
e.g. supportive family, FACTORS]
work history e.g. bullying, parents’
divorce, moving schools,
drug and alcohol use,
few close friends
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Trigger stressor
e.g. father dying

Environment
Lose structure, withdraw Feelings
from work, staying indoors where Anxiety, depression,
it’s ‘safe’ hopelessness, fear, loss,
Not allowing visitors into
home, more socially isolated anger, worthlessness

[MAINTENANCE
CYCLE]

Behaviour
Physiological
Withdraw and become isolated
e.g. cope by avoiding people Sleep deprivation
and activities; avoiding ‘threatening’ Lack of appetite
environments; drinking coffee
instead of eating Thoughts and psychotic symptoms
e.g. thinking ‘I’m being watched’;
‘I’m worthless’ ‘I’m special’

e.g. Voices say ‘die’, ‘bitch’; visions

of people who’d passed over;
confused thinking;

e.g. paranoid beliefs about being

watched and others trying to harm
me by poisoning me or running me over;
conversing with the deceased

FIGURE 8.2 Jo’s formulation

Source: Adapted from Beckian longitudinal CBT formulation discussed in Chadwick (2006); systemic
formulating discussed in Meddings et al. (2010); and Lake’s team formulation (2008).
 138 MARK HAYWARD ET AL.

Cognitive-behavioural therapy for psychosis (CBTp)

CBTp focuses primarily upon positive symptoms (voice hearing and delusional beliefs).
Its basic premise is that the beliefs a person develops about themselves (I am worthless
or I am very special and important), other people (they can’t be trusted and want to
harm me) and voices (have great power and know everything) may not be totally
accurate. These beliefs represent ‘best guesses’, but may be inaccurate due to the biases
in information processing that are common to everyone. CBT helps people make sense
of psychotic experiences and thoughts in the light of their life experience, and how
these experiences impact upon their lives.
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During CBTp the therapist will encourage the client to review the evidence for
and against a particular belief. For example, if the client believes the voices they hear
are all powerful and can make bad things happen, evidence will be reviewed that
supports and does not support this belief. If there are times when the voice has said
bad things will happen but they have not happened, the therapist will help the client
reflect upon the meaning of such a contradiction. The client may realise that although
the thoughts had previously been a helpful adaptation to life’s challenges they may no
longer be helpful or accurate in the current context – they start to question the belief
and what the voice says, and the therapist and client may together identify an
alternative belief; for example, that voices don’t always tell the truth. Evidence for this
alternative belief may then be gathered and its accuracy assessed (for a step-by-step
guide to these interventions see Hayward et al. (2012; voices hearing), and Freeman
et al. (2006; paranoid beliefs).
Throughout CBTp the therapist and client work together to test the accuracy of
strongly held beliefs. This is called ‘collaborative empiricism’. The therapist is not trying
to persuade the client to revise or give up their beliefs. Rather, the therapist is enabling
the client to disengage from biases in information processing that restrict the range of
information available, and to consider a wider array of information before making
decisions. At the end of this process the client may decide that their strongly held
(delusional) belief fits accurately with the evidence, or they may decide that an
alternative explanation has some credibility.

Family interventions for psychosis

About half of those people who experience serious mental health problems live with
family or friends. For those living independently, family, friends and house mates
remain important. Living with someone with psychosis is a multi-faceted experience
– people with psychosis contribute positively to such relationships (Coldwell et al.,
2010); yet it can also be stressful and feel burdensome (Fadden, 1998). People who
have supportive relationships do better than those who have less support, or more
stressful, critical or over-protective ones (Kavanagh, 1992). It is vital that mental health
services offer information and support to friends and family as well as to the person
experiencing psychosis.
There is long-established evidence for the effectiveness of family interventions for
psychosis, especially schizophrenia spectrum disorders (Burbach, 1996; Fadden, 1998).
Family intervention meetings focus on improving relationships and reducing any
 WORKING WITH PSYCHOSIS 139

perceived criticism or hostility; developing a shared understanding of the psychosis,

how it affects everyone, and that the problems are not anyone’s fault; developing
coping strategies and ways of dealing with practical challenges; coping with life-cycle
issues such as losses or people leaving home; separating the problems from the person
and separating each member of the family so that they can live their own lives;
appreciating each other’s strengths; and exploring ‘vicious circles’ that may be keeping
problems going. For example, Ben copes with voices which persecute him and his
mother by withdrawing to his room and shouting at them. His mother finds this
stressful as she has heard that it is better for him to remain active, so she tries to cajole
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him but he experiences this as criticism and this makes the voices worse. The family
intervention may help them make sense of this and to appreciate how each of them
is trying to do their best for the other; how Ben is trying to protect his mother and
how she is trying to do what the clinical team have suggested. For further reading and
case examples, see Meddings et al. (2010) or Burbach et al. (2007).

CASE EXAMPLE1

This case example provides an overview of one kind of psychological intervention –

group person-based cognitive therapy (PBCT) for people who hear distressing voices
(see Focus 8.1 for a brief description of PBCT), and follows the progress of one
particular client through a group process.
Group PBCT was offered to eight people who heard distressing voices over 12
90-minute sessions. The group was facilitated by two clinical psychologists. Jessica was
referred to the group by a member of the clinical team that cared for her. She heard
voices which told her to harm herself and made critical and abusive comments. Jessica
responded by cutting her arms and trying to hide from the voices. She rarely left her
home and felt very anxious about attending the group.

Acceptance, mindfulness and psychotic experiences

Mindfulness is increasingly being used with positive effect across a range of
health conditions. Mindfulness is an approach based on practising a particular
form of non-judgemental attention to present moment experiences, drawn
originally from methods in Buddhist meditation. Brief mindfulness practices
are being used within therapies that encourage people to accept their
psychotic experiences rather than battle against them, and focus instead
FOCUS 8.1

upon valued activities and goals. Person-based cognitive therapy (PBCT) is

one such approach, building on the strengths of CBTp by combining cognitive
and behavioural approaches with brief mindfulness practices. PBCT can be
syndrome (psychosis) or symptom (delusional beliefs or distressing voices)
focused (Chadwick, 2006).
 140 MARK HAYWARD ET AL.

Description of therapy through its phases

Mindfulness practices (every session)

One of the therapists led the ten-minute mindfulness practice and verbally guided
members through a ‘body scan’ (scanning the body from head to toe, paying attention
to what is happening in each part) and a focus upon the breath (paying attention to
the in-and-out breath without trying to change it in any way). The guidance included
instruction to bring awareness to the full range of cognitive and emotional experience
– thoughts, feelings, voices, images – and invited group members to notice their minds
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wandering and bring their attention back to the breath if they wished to do so. In this
respect, noticing was emphasised as the first part of a two-part process – and one that
created a choice about whether to allow oneself to be caught up in an internal (voice-
hearing) experience, or to bring attention back to the breath. This conceptualisation
encouraged group members to exercise agency and make their own decisions about
how to relate to voices.
Group members engaged well with the practices from the outset, and readily
accepted the central role of mindfulness within the therapy. The initial practices offered
a novel experience to Jessica and she became concerned about not practising ‘properly’
or ‘not getting it’. These concerns were reflected upon during the sessions and
normalised. Jessica’s voices were often active during practices and she was invited to
describe the process of noticing voices and her subsequent response. On some
occasions Jessica was able to focus her attention on her breathing during the mindfulness
practice and she noticed her voices fading into the background. This was accompanied
by feelings of calm and peacefulness.
ABC model (sessions 2 to 3)
During sessions 2 and 3, there was a focus upon collaborative discussion of feelings
and behaviours that are commonly associated with hearing voices, including the impact
of beliefs about voices and beliefs about self. This was discussed using the ABC model.
An example is given in Table 8.1.
Subsequent discussion then focused upon how different beliefs and thoughts about
the same experience (i.e. hearing a voice) could result in different consequences. This
was again formulated using the ABC model and an example is given in Table 8.2.

TABLE 8.1 The ABC model: an example

Activating event Beliefs and thoughts Consequences
A B C

Voice comments Beliefs about voices Feelings

‘You are a bad mother, ‘Voices are powerful’ Anxious

if you go out I will hurt ‘Voices have control’ Low in mood
your daughter’
Beliefs about me Behaviour
‘I have no control’ Stop doing the things
‘I am weak’ I want to do
‘I am bad’
 WORKING WITH PSYCHOSIS 141

TABLE 8.2 The ABC model: an example

Activating event Beliefs and thoughts Consequences
A B C

Voice comments Beliefs about voices Feelings

‘You are a bad mother, ‘Voices are lying again’ Proud of myself
if you go out I will hurt ‘Voices don’t have total Enjoyment
your daughter’ control’

Beliefs about me Behaviour

‘I am strong’ Go to work
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‘I have some control’ Spend time with friends

Read a good book

As members began to talk about their voice-hearing experiences the sense of

universality (I’m not the only person who hears voices) became apparent. This is a
common and powerful experience in groups and was particularly striking for Jessica
who had only ever spoken to mental health workers about her voices.
Personal control (sessions 4 to 6)
The focus during sessions 4 to 6 was upon collaborative discussion of the belief that
voices have control over us. Discussions sought to assess the accuracy of this belief,
using questions such as:

1 What is the evidence that the voices have control over us?
2 Is there any evidence that the voices do not have control over us (Table 8.3)?

All the evidence gathered was reviewed and group members were asked to reflect on
what this evidence said about themselves and the voices. Members were particularly
struck by Jessica’s courage as she resisted voice commands to cut herself. Through
collaborative reviewing of the evidence, participants developed the insight that they
had some personal control, even when voices were around. This was subsequently

TABLE 8.3 ‘Voices have control over us’

Evidence supporting this idea Evidence not supporting this idea

Last week voices told me to harm myself Yesterday voices told me to cut myself and
and I cut my arms. I refused to obey them.
Voices told me not to ring my friend last Voices made threats that something bad
night and I didn’t. would happen if I went out on Tuesday
but I went out anyway and nothing bad
happened.
Voices told me I was stupid and should Voices told me that my friend didn’t like me
stop reading my book, and I stopped and not to bother calling them, but I picked
reading it. up the phone and called them. They
seemed really pleased to hear from me and
we met up for a coffee.
 142 MARK HAYWARD ET AL.

TABLE 8.4 The ABC framework: an example

Antecedent event Beliefs and thoughts Consequences
A B C

Voices are around and tell ‘I have some personal control Feelings
me to cut myself. even when the voices are Pride, enjoyment.
around.’
Behaviours
Don’t cut. Go out. See
friends. Do things I enjoy.
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Voices are around and tell ‘Voices have control over Feelings
me to cut myself. me.’ Anxious, depressed,
angry.

Behaviours
Cut myself. Stay at home.
Avoid seeing people. Hide
in bed.

used to examine the difference between believing that voices had total control, and
believing that members themselves had some control, which was again illustrated using
the ABC framework (Table 8.4).
Members were guided to consider how their day-to-day lives might be different if
they began to believe they had some personal control, and acted in accordance with
this belief. Individuals were encouraged to plan enjoyable activities to do outside of
the therapy (e.g. going to the shops, seeing friends) which supported the belief that
they had some personal control even when the voices were around. Jessica chose not
to hide from the voices by staying in bed, and would try to go out and see friends
instead.
Positive self-beliefs (sessions 7 to 10)
Sessions 7 to 10 focused upon individuals’ views of themselves. Members were
introduced to some of the cognitive biases that can maintain negative self-beliefs
(described in the aetiology section above), and were encouraged to notice, and reflect
upon, examples based on their own experiences. Jessica recalled the way her parents
neglected her and criticised her whatever she did – leaving her feeling like a worthless
failure.
Members were also encouraged to recollect positive beliefs about themselves, or
times when they had felt okay about themselves. This was very difficult for members,
as their views of themselves were dominated by negative self-beliefs. Consequently,
when asking members to reflect upon times when they felt okay about themselves, it
was helpful to ask:

• What was happening? (e.g. helping a friend with something)

• How did you feel? (e.g. feeling proud)
• What did this experience mean about you as a person? (e.g. ‘I am a good person’,
‘I am valued’, ‘I am helpful’).
 WORKING WITH PSYCHOSIS 143

This facilitated the development of, and reflection on, positive experiences of self.
Jessica spoke of the care that she was able to provide for her partner and children, and
how much they appreciated this. In addition, mindfulness was used to bring full
awareness to positive experiences, even though such experiences were perceived to
be infrequent. This process became easier and more fluid as members gained experience
of noticing positive experiences of self. When Jessica reflected on a positive experience
of herself, there was a sense of her visually growing in stature and confidence – sitting
upright, smiling and seeming ‘bigger’. These changes were highlighted to the group
and reflected back to Jessica.
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Looking back and forward (session 11 to 12)

During the final two sessions, individuals were invited to discuss what they each learned
from therapy and what they planned to take forward into their daily lives. Jessica spoke
of trying to do the following:

• Practise mindfulness every day or as often as seems helpful.

• Remind myself of the evidence from my own life that I sometimes have control
even when voices are around.
• Do what I want to do and not what the voices tell me to do.
• Regularly remember a positive experience when I felt okay about myself as a
person.

At the end of the group Jessica still heard voices that told her what to do and criticised
her. She still cut herself occasionally and tried to hide from the voices by going to
bed. However, these instances occurred less frequently as Jessica believed she had some
control and was able to resist the commands of the voices when she felt strong enough.
This personal control helped Jessica feel okay about herself and she was able to notice
and reflect upon experiences that were positive. Jessica was able to leave the house
occasionally and enjoyed spending time with friends whom she had not seen for a long
time.

TEAM WORKING

Most people with psychosis who need to access mental health services are seen by
multi-disciplinary teams. Outcomes are better when professionals work together in such
teams. Jo worked with a community psychiatric nurse (CPN) in an Early Intervention
in Psychosis Team. She coordinated Jo’s care, arranged for her to see a psychiatrist
who prescribed medication and referred her to a support group. It was she who realised
that Jo had been experiencing bipolar affective disorder for a while and that her dad
dying had triggered this episode. The team psychologist met with the CPN and the
rest of the team and helped them develop a formulation about how to make sense of
what was going on for Jo and what might help (see Figure 8.2). The psychologist also
consulted with the CPN working with Jo about how she could use psychological
approaches in their weekly meetings.
After about a year, Jo met with peer support workers who used their personal
experience of mental health problems to help others with similar difficulties. She saw
 144 MARK HAYWARD ET AL.

a vocational specialist who helped her to decide to get a job in mental health – she
helped with job search, put her in touch with other peer support workers and helped
her write her CV. Work gave Jo a sense of purpose, structured her time and kept her
updated on different ways of keeping well.
Modern medication and meaningful work are as effective as CBTp and family
interventions in improving recovery with psychosis. Evidence is growing about how
working with a peer who has personal experience of psychosis is also effective,
improving empowerment, confidence and self-esteem and reducing time spent in
hospital (Schizophrenia Commission, 2012). Jo now works as a peer trainer with Sussex
Recovery College and as a peer support worker. Peer support workers help people
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identify and follow their own goals, sometimes using psychological and recovery-
oriented techniques. For example Jo recently supported someone to achieve their goal
of going to London through problem-solving, grading activity whereby they started
with a short train journey, and keeping a diary of achievement. She helped them
develop a personal recovery plan to monitor their wellness and take actions to stay
well. She finds the Recovery College a good setting to experience the equality of
clinicians working with peers to co-produce and co-deliver trainings about mental
health to people with mental health challenges, their relatives and friends and other
staff.

CRITICAL ISSUES

Research is currently being undertaken to try to enhance the effectiveness of

CBTp. A further body of research relates to the availability of CBTp, as it is currently
offered to only a minority of people with psychosis (APPGMH, 2010). In response
to the need to enhance effectiveness and availability, a number of psychological
interventions are being developed that may be beneficial for and made available to a
broader range of clients. Many of these interventions have the following elements in
common:

• Positive beliefs about the self: CBTp has tended to emphasise the need to address
negative beliefs about the self. Therapies for people hearing distressing voices have
recently focused not upon negative self-beliefs but upon the enhancement of
positive beliefs about the self (see case study for an illustration of this approach).
This work focuses upon the re-enactment of times when the client has achieved
something and felt good about themselves (Dannahy et al., 2011; Van der Gaag
et al., 2012). The aim is to strengthen positive beliefs about the self and to achieve
a more balanced view of self as sometimes negative and sometimes positive.
• Acceptance and mindfulness: Therapies are increasingly focusing on finding ways to
live satisfying and fulfilling lives in spite of psychotic experiences, rather than
necessarily aiming to remove these experiences. Therapies that include mindfulness
meditation such as PBCT (described in the case study) target acceptance in this
way. Acceptance and commitment therapy (ACT; Morris et al., 2013) is another
increasingly popular therapy that uses a range of techniques (including mindfulness)
to help clients accept their psychotic experiences and invest energy in alternative
valued behaviours and activities.
 WORKING WITH PSYCHOSIS 145

• What needs to change? CBTp has typically focused upon delusional beliefs and voice-
hearing experiences in order to reduce associated emotional distress. Innovative
approaches are currently exploring the impact of focusing upon other problems
that are experienced by people with psychosis, rather than focusing upon the
psychotic experiences themselves. Daniel Freeman advocates an interventionist–
causal model approach, which focuses upon one putative causal factor at a time
(e.g. worry and sleep problems – see Focus 8.2), showing that an intervention can
change it, and examining the subsequent effects on the delusional beliefs (Freeman,
2011). Other interventions being developed focus upon the prevention of social
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disability (e.g. Fowler et al., 2013) and the enhancement of interpersonal relating
(e.g. Hayward et al., 2011).

CONCLUSION TO JO’S STORY

Since being diagnosed and getting the right medication and treatment I feel my life has
turned around. My personal relationships have improved and I am now engaged to
marry my partner who supported me through the psychosis. Working in mental health
services gives me a sense of purpose and constantly reminds me how strong people
can be and how much easier it is to get well when you feel supported.
Talking through my experience with professionals has helped me greatly as well as
attending support groups, practising mindfulness and listening to others’ stories. I have
a recovery plan so that I make sure I eat properly, get enough sleep and avoid too much
stress. I no longer suffer psychotic symptoms and using the different techniques I have
learned over the last few years such as CBT, I no longer need to take medication.

Worry and sleep

A recent theme within the psychosis literature has been to identify key non-
psychosis symptoms associated with emotional distress and to target these
symptoms in treatment. Freeman and colleagues have highlighted this
approach in their work on worry and sleep difficulties in people with
persecutory delusions. By placing the focus of treatment on these everyday
issues and utilising basic treatment strategies from the anxiety and sleep
literature, a ‘normalising’ framework is adopted from the outset that
promotes engagement and motivation. There is emerging evidence that brief
high-volume interventions targeting worry and sleep not only lead to
improvements in worry and sleep but also in paranoia. These brief
FOCUS 8.2

interventions for worry and sleep have the potential to address the limited
availability of psychological interventions for people experiencing psychosis.
Due to their simplicity, the interventions may be delivered to individuals or
groups/courses by a broad range of mental health professionals following a
short period of training.
 146 MARK HAYWARD ET AL.

KEY CONCEPTS AND TERMS

• Hearing voices • Information • Cognitive-behavioural

• Delusional beliefs processing therapy
• Trauma • Bio-psychosocial • Family interventions
• Stress-vulnerability approach • Mindfulness
• Self-esteem • Formulation • Recovery
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LEARNING OUTCOMES

When you have completed this chapter you should be able to:

1. Know what features or symptoms are characteristic of psychosis and have an

awareness of the types of psychological difficulties suffered by people
experiencing psychosis.
2. Have an understanding of the psychological and societal impact of psychosis.
3. Have an understanding of the psychological theories or models that are relevant
to psychotic experiences.
4. Have an understanding of the approaches used by clinical psychologists to treat
psychotic experiences – and the evidence base for these.
5. Have an understanding of how assessment, formulation, intervention and
evaluation may be used in a psychologist’s work with a specific case of the
positive symptoms of psychosis.
6. Be able to provide a critical appraisal of the different intervention approaches for
psychosis.

SAMPLE ESSAY TITLES

• Discuss the factors which may play a role in the cause and maintenance of
psychosis.
• How can the effectiveness of cognitive-behavioural therapy for psychosis be
enhanced?
• How can people with psychosis be helped to recover? What role can clinical
psychologists play in facilitating this recovery process?
• If someone is experiencing psychosis, how do we know whether they are getting
better?
 WORKING WITH PSYCHOSIS 147

NOTE

1 Adapted from a case example in Hayward et al. (2015). PBCT for distressing psychosis. In
B. Guardiano (Ed.). Incorporating Acceptance and Mindfulness into the Treatment of Psychosis:
Current trends and future directions. Oxford: Oxford University Press.

FURTHER READING
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British Psychological Society (2014). Understanding Psychosis and Schizophrenia: Why people
sometimes hear voices, believe things that others find strange, or appear out of touch with reality, and
what can help. A report by the British Psychological Society Division of Clinical Psychology.
Leicester: BPS.
Chadwick, P. (2006). Person-based Cognitive Therapy for Distressing Psychosis. Chichester: Wiley.
Hayward, M., Strauss, C. and Kingdon, D. (2012). Overcoming Distressing Voices. London:
Constable & Robinson.
Repper, J. and Perkins, R. (2003). Social Inclusion and Recovery: A model for mental health practice.
London: Balliere Tindall.
Velleman, R., Davis, E., Smith, G. and Drage, M. (2007). Changing Outcomes in Psychosis:
Collaborative cases from practioners, users and carers. Oxford: BPS Blackwell.

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 9 Working with people
with personality
disorders
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Brian Solts and Renee Harvey

JANE’S STORY

I’m 35 now and for as long as I can remember I’ve been involved with Services. As a
child I was in and out of foster care as life at home was just one big mess. My parents
drank heavily, and all my brothers and sisters – including me – were neglected,
physically and emotionally. When I was 7, my mum’s brother moved in, my so-called
uncle, and that’s when the sex abuse started. I was moved into care because no one
could understand why I was so unhappy all the time, but I couldn’t tell anyone, he made
me promise, and anyway he was pretty controlling and scary. I should have been safe in
care but there were people who hurt me and interfered with me.
I started self-harming when I was 13 or 14. It was a complete distraction from all the
mess and unhappiness around me, cutting my arms, being in control of something, and
letting the pressure out. Then I got pregnant by an older guy when I was 16 and he
promptly dumped me. That was a terrible time. I was utterly desperate and so
vulnerable, and I ended up giving my baby up for adoption. I will always feel guilty for
that.
I had to leave school, though I was pretty rubbish there, and just couldn’t focus or
concentrate on anything, and didn’t really have anyone I could call a friend, someone
who really knew me and what my life was like. I ended up going from one job to the
next, supermarkets, cleaning, you name it. So boring I couldn’t hack it.
Then I really started hurting myself bad, so alone, so depressed, so much wanting
not to exist, so needing to be dead. Drinking helped, as did smoking weed, but that
feeling of nothingness, the deadened peace, never really lasted and I ended up doing
some pretty stupid things with people. Don’t even go there. I was 20 and going from
one fella to the next. Then I started being knocked around and was hurt so badly one
time I just did it, tried to kill myself, that’s when I first went to the mental hospital. I was
in and out of the wards, it was like a pattern, pick myself up and start all over again and
 WORKING WITH PERSONALITY DISORDERS 151

then bam, I was back to square one. The shrinks and the therapists tried to help but it
was useless, and I just hurt myself more and more. I think they were as close as I was
to giving up, maybe more so.

SUMMARY

What does it mean to say that someone has a ‘personality disorder’? Can we even use
the word ‘disordered’ when we still cannot clearly define what ‘normal’ is? What we
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can unquestionably say, whether as a qualified professional or anyone else, is that we

all know people who struggle with severe challenges to living a ‘normal’ life, who seem
to have had more than their fair share of difficulties and personal unhappiness, and who
use extreme and often very damaging ways to try to cope.
This chapter will look at approaches to understanding how the personality traits and
behaviours of a person may develop from childhood to adulthood, and become increasingly
entrenched and destructive in nature. We will look at how this may result in a formal
diagnosis of personality disorder. There are several key debates. For example, does
diagnosis provide any guidance on how we might help someone (the usual reason why
diagnosis is made for any condition)? Certainly no other psychiatric category creates more
controversy and negative responses in most people. Are the potentially negative
consequences of the diagnosis balanced by potential benefits?
The chapter will also look at how a clinical psychologist might work within a health
care system to try to facilitate directly and indirectly the process by which people with
personality disorders not only merely cope but also recover. We will focus particularly
upon borderline personality disorder (BPD), as this is by far the most common presenting
condition in clinical services.

INTRODUCTION

We are all a unique product of our nature (i.e. our genes and innate temperament)
and nurture (e.g. the environment in which we grow up), and this shapes our adult
personality. This developing personality sets out who we are, our core identity, and
is a result of how we have come to know ourselves, through the eyes of others, as we
grow up and experience the world. It also defines how we relate to and are experienced
by others. We tend not to think of personality as a ‘static’ state; rather it operates at
the interface between our inner and outer worlds, making sense of our relational world
and how best to interact with others.
Unlike many other clinical presentations you will read about in this book,
personality disorders are not medical illnesses as such and do not fit neatly into a medical
model. The behaviour we witness in someone with this diagnosis may be extreme,
for example, impulsive dangerous behaviour or a complete shut-down from human
relationships. It often represents the final common pathway of a behavioural pattern
that was essential for psychological or actual survival in infancy and childhood, but is
 152 BRIAN SOLTS AND RENEE HARVEY

no longer an effective solution in adulthood. Working with people with this diagnosis
tends to also provoke extremes of emotional response in those who try to help and
we think this is because the manifest problem itself is interpersonal. For the clinical
psychologist involved, their input can be vital in helping others, including the family,
make better sense of the here-and-now relationship difficulties and to understand better
the extremes of behaviour. A bio-psychosocial formulation enriches the medical
diagnosis and enables us to think about how best to intervene without making things
worse for everyone involved.
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THE DEVELOPMENT OF A PERSONALITY DISORDER

So how do personality disorders come about? If we think about early infant develop-
ment we are all born with unique temperaments, which will be influenced by things
like our attachment relationships (the emotional bond between parent and child that
mediates safety and exploratory behaviours), childhood illnesses and the environment
(Ainsworth et al., 1978). An early attachment to a secure caregiver who is able to
respond to the emotional needs of a child, along with a fairly straightforward tempera-
ment, enables a child to develop a secure sense of themselves or their personality that
will help them trust others, and be trusted by others, in later life.
Children who suffer more difficult or traumatic early life experiences must learn to
adapt their emotions and behaviour to maximise their connection to their caregiver
(e.g. by learning not to express emotional needs that may lead to rejection) and
minimise risk (e.g. never expressing anger that may lead to feared abandonment). How
a child shapes their personality to cope with difficult childhood experiences will depend
upon a child’s temperament. Yet, while these ways of coping may be adaptive in
childhood (the best way of coping in a difficult environment), people who go on to
attract a diagnosis of personality disorder have usually not learned how to outgrow
the early pattern of behaviour that was so crucial for psychological survival in
childhood. Thus the ways of coping in childhood become rigid, inflexible and
unhelpful ways of coping in adulthood. If our personality cannot flex according to the
relational need, for instance, adapting our behaviour so that we can work with others
or raise a child, then people end up getting stuck in patterns of relationships that are
ultimately self-defeating and reinforcing of the maladaptive behaviour. This dynamic
is at the core of all personality disorders and represents the ‘failure to achieve adaptive
solutions to life tasks’ (Livesley, 2004, p.19).
One example is James, who grew up in foster care having been severely emotionally
neglected and physically abused for the first few years of his life. He was a suspicious
and nervous child who rarely went to others for comfort. His foster carers would try
hard to get close to him, but he would push them away, so he was never seen as a
rewarding child to be with. He always kept himself to himself and when he started to
struggle at school he never asked anyone for help. In the playground, he often got
into fights and never developed friends. As a baby, shutting off from harmful
relationships may have been a good form of psychological self-protection in those early
years, but in school it got him into trouble, and in foster care led to the breakdown
of placements over and over again. As an adult, James still cannot sustain close
 WORKING WITH PERSONALITY DISORDERS 153

relationships. Desperate to be liked and to have friends, he is overly generous and is

frequently exploited for money; when he realises this, he becomes aggressive and
rejecting of others, isolates himself for long periods of time, and relapses into depression.
He then becomes desperate again for friendship and the cycle begins again.

MAKING A DIAGNOSIS

The issue of diagnosis is highly controversial. It is a ‘sticky label’ that comes with
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prejudice and rejection (Haigh, 2002). It thus becomes very hard for someone to escape
the judgemental attitudes they sometimes encounter. This can cloud others’ views of
the person with a personality disorder in all its aspects, such as assuming that because
someone has this label, they are not capable of being a good parent, or that any of
their other difficulties could be explained by the diagnosis, including physical
symptoms. People receiving the diagnosis sometimes also judge themselves, concluding,
for example, that there is something deeply wrong and ‘unfixable’ about them. But
for some, getting a diagnosis comes as a relief after years of confusion and brings a
sense of knowing what one is dealing with. Pragmatically, a diagnosis should enable
people to access help, and helps service providers put arguments forward to
commissioning bodies to provide funds to develop services. Not diagnosing someone
who needs help is arguably a worse option. There is also a growing consensus that
individuals moving around mental health care systems without the right approach may
actually get worse.
One controversy surrounding the diagnosis of BPD for some people is the overlap
with post-traumatic stress disorder (PTSD) and particularly the notion of ‘complex
PTSD’. Many people prefer this as a diagnostic label for BPD. However, current
opinion in the literature favours the notion that they overlap but are not the same.
Some individuals fall into one camp but not the other. A clear focus on what each
individual needs would hopefully prevent individuals being treated as having either
one or the other, or seeing them as needing help with both if necessary.
Diagnostic methods reflect the complexities of actually reaching an accurate
diagnosis: ICD-10 and DSM-5 do not overlap completely and the latter system, having
recently gone through a major revision, rejected all proposed changes because of
criticisms and reverted back to DSM-IV, a system many know is fraught with
problems (Mullins-Sweatt et al., 2013). The diagnosis eventually given depends too
often upon who is doing the diagnosing (Treloar and Lewis, 2009). One potential
advantage of the new system in the Appendix of DSM-V is that it provides a
dimensional approach, which allows for placing individuals on a continuum from
‘normal’ to very severely affected, and challenges the idea that there is a fixed cut-off
point somewhere in the middle.
It is important that clinicians follow a sound procedure for determining the presence
both of the personality disorder as well as any other problems that may exist
concurrently. Clinicians can access a range of interview or questionnaire-type
instruments to help with diagnosis, such as SCID-II (First et al., 1997) or the MCMI-
III (Millon et al., 2009), among others. These instruments should only be interpreted
within the context of a full clinical picture, and benefit from observations from people
 154 BRIAN SOLTS AND RENEE HARVEY

who know the person best, though this may also be fraught with difficulties if a family
member or carer is known to be part of the problem. There is probably more to be
gained than not in terms of having a diagnosis, as long as this is based on a number of
different sources of information and reports, and is never used as shorthand for
describing patients or colleagues with whom we simply do not get on.

EPIDEMIOLOGY OF PERSONALITY DISORDERS

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Research suggests that about ten per cent of people have problems that would
meet the diagnostic criteria for Personality Disorder. Estimates are much higher
among psychiatric patients, although they vary considerably: some studies have
suggested prevalence rates among psychiatric outpatients that are in excess of 80
per cent. Between 50 per cent and 78 per cent of adult prisoners are believed to
meet criteria for one or more personality disorder diagnoses, and even higher
prevalence estimates have been reported among young offenders.
(Alwin et al., 2006, p. 1)

The epidemiology of personality disorder is fraught with problems. Unlike in medicine

where pathology is often a discrete set of cellular symptoms, measuring psychological
illness and marking the point at which something ceases to be normal and becomes
‘disorder’ is not an exact science. The tools we use to ‘measure’ personality disorder,
such as self-report questionnaires, face-to-face interviews or behavioural indicators, will
all be subject to bias.
What we see ‘under the microscope’ in personality disorder is essentially
interpersonal, which inevitably introduces subjective bias. In order for us to accurately
predict prevalence and incidence we must assume that the concepts we are studying
are valid and reliable constructs, not influenced by social norms. Yet so-called deviation
from cultural norms is part and parcel of how someone might come to attract this
diagnosis in the first place. There aren’t many disorders that, in theory, can be cured
just by boarding a plane and travelling to another country. In terms of gender, it is
interesting that in Western countries women are more likely to be diagnosed with
BPD, whereas men tend to be diagnosed as antisocial. Is this a ‘true’ feature of these
conditions, or further evidence of cultural and social bias?

BORDERLINE PERSONALITY DISORDER (BPD)

It is impossible to look at the characteristics of all personality disorders in one chapter,

and looking in more detail at the aetiology of all personality disorders would require
a whole book, so we will focus on one: borderline personality disorder (BPD). We
have chosen BPD because this is by far the most common presentation in adult mental
health services and has also seen the most significant advances in evidence-based
approaches over the past two decades.
 WORKING WITH PERSONALITY DISORDERS 155

What are the types of psychological difficulties that may

occur in BPD?
A new system has been proposed for understanding BPD in DSM-V (APA, 2013).
The core diagnostic features are as follows.

A disorder of the self

This is where people have a poor self-identity and struggle with their sense of who
they are and what they are like as people. Their identities may change dramatically,
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depending on current relationships or environments. A question such as ‘Tell me about

yourself’ may be met with confusion and distress, such as ‘I don’t know what to say,
I’m nothing’.

Emotional instability
People with BPD have intense, rapid and dramatic fluctuations in mood, sometimes
without obvious precipitants. When stressed, individuals may become angry, severely
depressed and anxious, develop paranoid thoughts and even experience dissociation
and transient episodes of psychosis. In a clinical setting, an individual’s mood may
change dramatically within the space of a single session or even moment by moment.
An important skill for the psychologist is learning to stay calm and constant in the face
of highly charged affect while maintaining and communicating empathy. For example,
Mary (29) began her session in a positive mood, talked about her weekend, suddenly
got upset and ran from the room.

Behavioural instability
In BPD, impulsive decision making and destructive (mainly self-destructive) behaviours
disrupt the individual’s life and can interfere with engagement and progress in
assessment and treatment. For example, four weeks into a 20-week group, Sue (25)
wrote to say she wouldn’t be back, as she had decided to go to America to be with a
person she had met on the internet a week previously.

Interpersonal instability
For people with BPD, relationships are generally unstable, characterised by frequent
chaotic upheavals. Many people with BPD suffer intense fears of abandonment and
make active attempts to avoid others leaving them (whether real or imagined). In the
therapeutic relationship it may take a long time for a person to develop trust in the
psychologist. They may also, paradoxically, form intensely dependent relationships very
quickly. They are likely to be highly sensitive to change and unpredictability in any
aspect of the psychologist’s behaviour or in relation to arrangements made. Any changes
in the routine such as holiday breaks and especially endings, such as when a professional
is leaving, should be discussed well in advance. For example, John (35) begins each
meeting with his psychologist with ‘Is today going to be our last session?’
 156 BRIAN SOLTS AND RENEE HARVEY

Aetiology of BPD
Biology and our early environment
It is thought that people who go on to develop BPD start out in life with strong
temperamental characteristics that lead to a propensity for high emotional reactivity.
A particularly difficult baby will be a challenge for most parents to ‘contain’ and help
regulate their emotional world, and without this we can speculate that there will be
a reinforcing negative interplay between emotional expression of the child and the
experience of being parented. Linehan (1993) and Blum et al. (2008) would view
someone with BPD as primarily having a dysfunction of the emotion regulation system,
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made worse when someone grows up within an emotionally invalidating relational

environment. According to Linehan, one of the most emotionally invalidating
experiences a child can have is abuse, so it is no surprise that there is a strong association
between a diagnosis of BPD and reports of childhood physical, emotional and/or sexual
abuse. Self-harm, drug and alcohol use, dangerous risk taking, abusive later
relationships, dependency: these may all be symptoms of a person who is struggling
to manage intimate relationships and their internal emotional system.
Emotions in the context of insecure attachment
Bateman and Fonagy (2004), strongly influenced by the work of Bowlby and attach-
ment theory, have focused our attention on the nature of early attachment relationships,
and in particular disorganised attachment patterns and the later development of BPD.
If an infant learns early on that not only is their attachment figure inconsistent and
unreliable, but also a source of terror, at times of stress in adulthood (e.g. relationship
breakups, managing conflict at work, being in need of help) the activation of the
attachment system becomes a source in itself of destabilising and dysregulating
emotions. In other words, it is not the case that people with BPD reject or will not
accept help; it is that they cannot, and in fact at times of stress it becomes impossible
to see others as a potential source of comfort and genuine help. This is what they refer
to as the breakdown of mentalisation. At times of stress, other people become a source
of fear. Self-harm and dangerous behaviour in this context may be seen as attempts to
‘reset’ the internal emotional regulatory system to more manageable levels, though this
may not be how others interpret the behaviour, which is easily labelled manipulative,
divisive, intentional or psychopathic. It is our view that the damaging behaviours we
see in people with BPD are not conscious attempts to control or damage others, though
this may be a secondary consequence.
It is hard for most of us to imagine how seeking help and being helped could lead
to a temporary mental breakdown. Yet remember, people with this diagnosis may be
biologically disadvantaged by having an emotional system that is quickly over-aroused,
may never have learned skills to regulate their emotional system, and, on top of this,
some will only have experienced attachment figures as abusive, controlling, humiliating
or downright dangerous.
Alwen’s (2006) bio-psychosocial model places attachment status (secure or insecure)
and our internal representational models of people at the interface between the
‘internal past’ experiences (psychological, social and biological) and the ‘external present’
symptoms of distress (behavioural, cognitive and emotional patterns) that are played
out in the here-and-now of everyday interpersonal relationships. In the absence of any
 WORKING WITH PERSONALITY DISORDERS 157

good-enough corrective relationship experiences, the survival pathway for someone

with BPD may be to look for extreme ways to manage extreme emotions that emerge
when trying to deal with people (e.g. partners, friends, managers). Drugs, alcohol and
self-harm, for instance, may be reframed as ways of coping with the extreme emotions
that emerge at times of relationship stress. It is thus common to see a repeat of abusive
relationship patterns in the here-and-now in response to a manager at work trying to
address difficult work behaviour, or indeed with mental health professionals trying to
help. If the internal working model that has developed through childhood has taught
someone repeatedly that getting close to others at times of stress is humiliating, shaming
and damaging, it is no surprise that people with this diagnosis can be so hard to help
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when they are experiencing symptoms of distress.

Theory and evidence for psychological intervention for BPD

The past provides a perspective, not an explanation. All the evidence-based

therapies for BPD, even those based on psychoanalytic principles, help patients
to put the past behind them and to foresee a future, in some cases, for the first
time. This is why getting better requires getting a life.
(Paris, 2010, p.155)

Just as there is no single determining factor that leads to the development of BPD,
equally treatment that only takes account of one aspect of the disorder is unlikely to
lead to recovery (Paris, 2010). For instance, a purely medical approach may eradicate

PHASE 1 PHASE 2 PHASE 3

‘Common factors’ Skills and life Psychological therapy:

management:
Attachment Dealing with trauma
Psycho-education
Trust Self-development
Skills: STEPPS (Blum et al.,
Hope 2008) or DBT (Linehan, 1993) An evidence-based therapy
for BPD (including art and
Recovery orientation Life skills other expressive therapies)

Housing
PLUS

Safety and risk Finances (Re-)engagement with

management: the community
Crisis planning Childcare
A satisfying quality of life
Support
Health Healthy relationships
Stabilising co-morbid
conditions (e.g. Work
addictions, eating Spiritual needs
disorders, depression)

FIGURE 9.1 A proposed model for treatment

 158 BRIAN SOLTS AND RENEE HARVEY

some symptoms, but increase the likelihood of impulsive self-harm by giving someone
the means of really hurting themselves (overdosing). Prescribing tablets alone may also
give someone the impression that they cannot develop their own internal skills for
managing their difficulties. On the other hand, a purely psychological approach might
reinforce victimhood and blame of others and neglect social factors such as poor
education, housing and poverty that might be equally important sources of distress.
In our local services we have developed a care pathway approach that breaks treatment
down into three phases, and emphasises the importance of a holistic and integrated
bio-psychosocial approach to recovery (see Figure 9.1 above).
Our pathway model is important, as it sets out a rationale for interventions aimed
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initially at stabilisation and risk management within a recovery-orientated approach.

This is prior to undertaking psychological therapy. You would not embark upon a
journey to climb Mount Everest without the appropriate gear (suitable clothing and
climbing equipment) or knowledge of what to do in a crisis. Likewise, we think it is
very unwise to embark upon a course of therapy if you do not know how to regulate
and manage your emotions safely, or what to do when things go wrong (as they
invariably do from time to time in therapy). For BPD, the goals of therapy need to
be realistic and made explicit, no matter how complicated the presenting picture looks,
so, if someone is not ready to give up self-harm or drug use, undertaking work on a
trauma would be too premature and potentially self-defeating for both patient and
therapist.
Bateman and Fonagy (2000) reviewed the literature on factors that are common
for all effective treatments for BPD. Treatments that work best are well structured,
devote time and effort to enhance motivation and adherence, have a clear focus upon
which both sides have agreed, are theoretically coherent for both therapist and patient
(i.e. everyone knows what they are meant to be doing!), are relatively long-term, and
encourage a powerful attachment relationship between therapist and patient that
enables the therapist to adopt an active stance. Finally, treatment needs to be well
integrated with other services available for the patient. This is extremely important
because of the potential for those around the patient to mirror early experiences of
growing up in inconsistent, chaotic, unreliable and confusing contexts.

CASE STUDY

Karen is a 35-year-old married mother of a 10-year-old daughter and a grown-up

daughter from her first marriage. She had been an inpatient on a psychiatric ward
for about two months when she first met Sam the psychologist. Prior to this, she
lived in staff-supported accommodation during the week, but spent weekends
with her family. She was known to take regular overdoses of prescribed
antidepressants and anti-anxiety medication ‘to knock myself out’. She had been
known to mental health services for about eight years following the death of a
new-born baby. She used services intermittently, presenting initially with severe
depression and intent to kill herself, but then she resisted attempts to help her
and withdrew until the next crisis.
 WORKING WITH PERSONALITY DISORDERS 159

The most recent crisis in many ways followed the same pattern. However, a
number of issues were destabilising the situation even further. Karen’s husband was
concerned that her behaviour was now beginning to affect weekends with her
daughter and he was signalling a wish to end the relationship. This led to a number of
aggressive outbursts from Karen followed by complete withdrawal and refusal to talk,
then a very serious overdose that necessitated several days in intensive care and
then admission to a psychiatric hospital. Once on the ward, the housing project
began taking action to withdraw their support because of the severity of overdosing
and concern that they could not manage her aggressive and suicidal behaviours.
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When Karen heard that they were taking action to evict her, she attempted to hang
herself in her room on the ward, only to be found, and cut down, by staff. Staff
began to take more and more action to stop Karen cutting or strangling herself during
the day, for instance, taking away potential ligatures such as laces, belts,
headphones or phone charger. Once staff got to the point where they had stripped
the room of bedding during the day, Karen became even more aggressive, and
complained to the authorities that she was being treated like a prisoner. In staff-
reflective practice groups, people spoke about feeling controlled and manipulated by
her behaviour and it was clear that trust had broken down on both sides.
This is a common dynamic when people with BPD are admitted to inpatient
wards, but is usually the last resort for professionals who are trying to manage the
accompanying high-risk behaviours to self (e.g. severe cutting, dangerous
overdosing, threats to jump off buildings). Unfortunately an admission is rarely able to
make social or psychological changes and has a tendency to become overly medically
focused. Attempts at recovery-focused self-management interventions can be
hampered by a tendency for people with BPD to regress into helpless dependency at
points of crisis as they seek idealised care and being looked after to escape their
dangerous feelings. If hospital systems do not take into account social and
psychological factors throughout the admission and prior to discharge, this will
further exacerbate the internal crisis for the patient, at which point there will be
further escalation of dangerous behaviours. Ironically, this may be all the patient has
left to survive the emotional turmoil of being cared for on the ward, or when facing
the prospect of discharge (abandonment).
When Sam the ward psychologist first got involved, he worked hard to remain
as neutral as possible in formulating what was going on and in thinking about the
most helpful way to intervene. This was not easy: his colleagues expressed
resentment at having to care for Karen, and, after sitting with the team and
reflecting on events on the ward, Sam remembered feeling afraid of meeting
Karen because of her anger and being overwhelmed by all the difficulties staff
were worried about, something he needed to process in supervision. Sam wanted
to really understand Karen, but the ward was so concerned about her behaviour
that no one had reviewed her history. He thought this was a good place to start
and was guided by Alwin’s (2006) bio-psychosocial model to help him think about
Karen in an attempt to better understand her.
 160 BRIAN SOLTS AND RENEE HARVEY

External present
Karen had poor general coping abilities, a chronic depressive mindset, and an
interpersonal style that made it very difficult to help her. She would reach out with
desperate cries for help, only to then reject it and withdraw into a mute and angry
state. Aggressive and hostile behaviour towards staff was, in Karen’s mind, justified,
because she felt she was being controlled and abused.
Outside of hospital, Karen led two lives. On the one hand, she was a mother and
wife at weekends, but on the other hand she withdrew into a drug-induced haze the
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rest of the time to avoid social interactions. Her inability to get her needs met by
professionals (the approach–withdrawal dynamic) probably mirrored what happened
with her husband and daughter. In this way, her interpersonal style left her struggling
to express or hold on to what she really wanted from life.
Karen had a very mistrustful relationship with her mother and saw her as the root
of most of her problems. She saw herself as a victim of her mother’s hatred and
therefore a worthless human being unfit to be alive. At times of stress, she tended to
locate the difficulties in other people alone, reinforcing her feelings of being
victimised and bullied by others, putting her on the offensive, and then she would be
experienced as victimising and bullying of others. In this way, her interpersonal
pattern repeated itself within the hospital setting.
Sam identified housing as a key destabilizing issue and, rather than avoid it out of
fear that she would hurt herself, Sam talked it through. He taught her skills to
manage the strong feelings this evoked and reviewed her options with colleagues
who were then able to present Karen with good advice. This intervention led to a
breakthrough – Karen asked her primary nurse to help her talk to her husband about
living arrangements, and this led to an increase in trust on both sides.

Internal past
Sam recognised the risk of forming an intense therapeutic relationship with Karen on
the ward when the team were working towards discharge from hospital. Whenever
staff prompted Karen to talk about her childhood, she became very distressed and
this led to self-harm. Sam helped the staff understand from existing clinical reports
that Karen always felt unwanted and unloved as a child, believing that her mother
preferred her older sister. She spoke about a very loving relationship with her father,
but this was at odds with reports that he was violent and had died when she was a
young teenager as a result of his own battle with alcohol addiction.
Karen blamed her mother for her father’s problems. After he died, Karen became
increasingly alienated from her family, refusing to go to school, making friends with a
‘bad crowd’, and eventually she left home at 16 to live with an older boy, only to get
pregnant and have her first child. Although she got married, this only lasted for six
months as it quickly escalated into violence on both sides. After being hospitalised
following one particularly violent incident, Karen left with her baby and had no further
contact with her husband. After this time, she had periodic episodes of depression
 WORKING WITH PERSONALITY DISORDERS 161

and anxiety, and there was a recurring pattern of emotionally intense but short-lived
relationships, until she met her now second husband. Although she described him as
dull, boring and everything she was not, she recognised how much stability he gave
her, including financial security for the first time in her life.
Sam was able to help staff steer themselves away from talking to Karen about her
past; rather he guided them towards here-and-now relationships and problem
solving.
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INTERFACE BETWEEN INTERNAL/EXTERNAL

This patterning of Karen’s internal and external world suggested an insecure-ambivalent

attachment style. In Ainsworth’s ‘strange situation’ test, Karen may have been the child
who would become distressed at the caregiver leaving, but then make alternate bids
for contact on reunion, with signs of angry rejection and tantrums (Ainsworth et al.,
1978). These are children that tend not to find comfort in their parent caregiver.
Sam helped staff not to take Karen’s verbal outbursts personally. He helped them
see why, given her past, the process of getting close to others activated an internal
working model of people who she expected to emotionally let her down, hurt or
abandon her when she needed them most. With no skills to regulate her emotions,
her interpersonal style puts her between a rock and a hard place. The more trapped
she becomes in a system that takes control, the more out of control her emotions get,
and the more her aggression kicks in as she literally fights for emotional survival.

WHERE SHOULD SAM INTERVENE?

One of the most important roles the psychologist played was to help the team develop
a shared understanding of Karen that went beyond the medical diagnosis. Staff can
struggle to step back and think in the face of hostile and highly charged emotion in
the patient. Sam provided space to ‘digest’ the emotions and map out Karen’s way of
thinking about people to help them empathise more readily and see that her aggression
was also a sign of attachment crisis. Rather than take more control during these times,
staff were encouraged to back off and not get into a position of confrontation. This
also applied to the self-harm. Karen often self-harmed after seeing her daughter, and
so staff began to provide more emotional support at these times rather than avoid
her, thinking she wanted to be alone. Karen found saying goodbye to her daughter
very difficult, and so staff started to model to Karen that she could put her feelings
into words rather than get angry. Once Karen developed more trust in staff, she talked
about her poor parenting skills and together they thought about a service that could
help her when she left hospital. Her daughter’s emotional needs were also flagged up
as Karen and her husband began to talk through with the team a more sustainable
solution for their living arrangements after discharge.
As staff began to regain their own sense of empathy for Karen, and recognised trigger
points for her anger and distress, the frequency of self-harm episodes lessened, and
Sam agreed at this point to do some skills-based work with Karen that included
 162 BRIAN SOLTS AND RENEE HARVEY

psychoeducation about her diagnosis. The contracted work was articulated clearly in
her care plan, as many people assumed that Sam would be offering a formal piece of
therapy work. Importantly, Sam was able to attend review meetings and meet with
her community team to ensure that everyone knew about the work that was being
done. Karen understood that this would be time-limited work aimed at giving her
more control over her emotions, though she was clear that she wanted the work to
continue after discharge. Sam had to be boundaried and experienced a real emotional
tug of war as he felt a pull to carry the work on after discharge. Supervision was essential
in helping him hold on to his role as an inpatient team member, and to maintain a
realistic and not devaluing view of the team in the community.
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Discharge from hospital is a real danger time for this group of patients, as feelings
of abandonment are triggered which further destabilise the patient and escalate risks
of self-harm and suicidal feelings. At these times, staff may feel manipulated and
controlled into not discharging the patients, so this point in treatment must always be
well thought through with clear crisis and risk management plans. Even when all goes
according to plan, patients will still feel punished and hurt at the prospect of returning
to the community when they still feel chronically suicidal. The real work for Karen
had only just begun as she started to make adult choices about the sort of life she wanted
to live.

MANAGING BORDERLINE DYNAMICS IN THE TEAM

With this group of patients, the best work occurs when everyone involved in the care
of the patient is signed up to the care plan. Support and supervision, often provided
by a psychologist or psychological therapist, helps the team work through difficult
feelings about the patient. If feelings are not checked, the team can end up re-enacting
unhelpful dynamics that mirror for the patient his or her own uncontained and
conflicted early life. Alternatively, if one member of staff goes the extra mile, they risk
being vilified by another who wants the patient to be discharged, and soon the team
may find itself divided and unable to make effective decisions.
A good team can work through differences of opinion and develop a boundaried
but fair care plan. The experience of being emotionally contained may be quite
novel for some people, and it is not uncommon for the patient to test out each staff
member to look for differences in boundaries, tolerance of risk, or personal beliefs
and attitudes. The role of the team is to understand and work alongside someone as
they re-evaluate deeply ingrained beliefs about who they are and the sort of world in
which they exist.

CRITICAL ISSUES

Psychologists are skilled in bringing together psychological theory into practice to help
others understand how best to intervene at critical points in a patient’s recovery. In
this chapter we have outlined the limitations of diagnostic frameworks that may be
quite arbitrary in determining the point along a continuum of functioning where
 WORKING WITH PERSONALITY DISORDERS 163

disorders begin. At the same time diagnosis can, when combined with a bio-
psychosocial formulation, help identify need and open up treatment pathways. We have
presented a care pathway approach for treating people with BPD and have explored
different ways in which psychologists may help. Providing individual therapy is only
one of many roles the psychologist may have in this area of work.
Helping people with entrenched and risky behavioural patterns, in the context of
damaging interpersonal dynamics, is not easy. Psychologists cannot do this work alone
and need to locate their interventions within the context of a whole-team approach.
We are all, however, human beings at the end of the day, and in this field of work
personal reflection, the ability to use supervision and support well, and doing work
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on our own personal issues in therapy, may be just as important as learning the tools
of our trade.

CONCLUSION

This chapter has explored some of the ways a clinical psychologist can contribute to
the care and recovery of people diagnosed with personality disorders. Psychologists
will contribute to a bio-psychosocial formulation of the presenting difficulties that will
try to address the repetitive and ultimately self-defeating patterns of relating to others
that make the lives of this group of people so unbearable. In psychiatric settings, it is
common to work with people who have a diagnosis of BPD. Although we argue that
there are pros and cons in having a personality disorder diagnosis, ultimately we think
this has allowed practitioners to make arguments to commissioners about how best to
develop services. We have developed a three-phase care pathway in our local services
that attempts to help people manage their presenting risks (e.g. suicidality and self-
harm) in the context of safe relationships; develop life skills that can help regulate their
emotions; and finally use psychological therapy so that they can re-engage with life
outside of professional services and make a meaningful recovery. We are very optimistic
about the contribution that psychologists can make in this area.

JANE’S STORY: HOPED-FOR RECOVERY

Okay, so my life has turned a corner. I had a great care coordinator, someone who made
sure I wasn’t forgotten, in my mental health team, and she really got my struggle, but
also challenged me a lot when I forgot appointments or did stupid things. I think she
really got the whole BPD thing. What is it they say, never judge a book by its cover. It
may look like I’m doing okay, turning up for things, catching buses, putting a bit of
make-up on, but inside I can feel like I am dying, literally. I wasn’t keen on the borderline
thing but my treatment changed when they said this is what I have. I did a group called
STEPPS which gave me real ways to manage my feelings better. Rather than cut or take
drugs I learned to direct myself differently and even to challenge how bad I was thinking
I was doing – my filters – that I might not be totally bad inside. Once I got better at
managing my feelings, I started to do some therapy so I could learn how to move away
 164 BRIAN SOLTS AND RENEE HARVEY

from just feeling like I was living in the past. They also gave me an occupational
therapist who helped me gain confidence in other life skills and even challenge me to go
back to study. I may not see myself as totally fixed – is anyone? – but at least I have let
my body heal and allowed my mind to get more peace.

KEY CONCEPTS AND TERMS

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• Personality • Bio-psychosocial and problem solving

disorder integrative (STEPPS)
• Borderline formulation • Dialectical behaviour
personality • Mentalisation- therapy (DBT)
disorder based therapy • Staff containment
• Attachment theory (MBT) and self-reflection
• Emotion • Systems training in
dysregulation emotion predictability

LEARNING OUTCOMES

By the end of this chapter you will have:

1 Developed an understanding of how our personality develops over time – and

the difficulties we can face as adults when we get stuck in particular patterns of
relating because of the personality structures we have developed.
2 Developed an understanding of the controversy and debates over the use of
‘personality disorder’ as a diagnostic label.
3 Gained an overview of what it means to be diagnosed with a personality
disorder and, in particular, to think about the challenges posed by those who
present for help with borderline personality disorder (BPD).
4 Grounded this thinking in a bio-psychosocial model of BPD.
5 Gained an ability to critically evaluate different treatment approaches.

SAMPLE ESSAY TITLES

• What are the advantages and disadvantages of diagnosing someone with borderline
personality disorder?
• What factors could contribute to the development of borderline personality disorder?
• The clinical psychologist’s role is to provide individual psychological therapy for
people diagnosed with borderline personality disorder. Discuss.
 WORKING WITH PERSONALITY DISORDERS 165

REFERENCES AND FURTHER READING

Ainsworth, M.D.S., Blehar, M.C., Waters, E. and Wall, S. (1978). Patterns of Attachment:
A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.
Alwin, N. (2006). The causes of personality disorder. In M.J. Sampson, R.A. McCubbin and
P. Tyrer (eds), Personality Disorder and Community Mental Health Teams. Chichester: Wiley,
ch. 3.
Alwin, N., Blackburn, R., Davidson, K., Hilton, M., Logan, C. and Shine, J. (2006).
Understanding Personality Disorder: A report by the British Psychological Society. Leicester: BPS.
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American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders.
Revised fifth edition. Washington, DC: American Psychiatric Press.
Barrachina, J., Pascual, J.C., Ferrer, M. and Soler, J. (2011). Axis II comorbidity in borderline
personality disorder is influenced by sex, age, and clinical severity. Comprehensive Psychiatry,
52/6, 725–730.
Bateman, A.W. and Fonagy, P. (2000). Effectiveness of psychotherapeutic treatment of
personality disorder. British Journal of Psychiatry, 177, 138–143.
––– (2004). Psychotherapy for Borderline Personality Disorder: Mentalization-based treatment. Oxford:
Oxford University Press.
Blum, N., St. John, D., Pfohl, B., Stuart, S., McCormick, B., Allen, J., Arndt, S. and Black,
D.W. (2008). Systems training for emotional predictability and problem solving (STEPPS)
for outpatients with borderline personality disorder: A randomised controlled trial and
1-year follow up. American Journal of Psychiatry, 165, 468–478.
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Clinical Interview for DSM-IV-R Axis II Personality Disorders (SCID-II). American
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PublicationsPolicyAndGuidance_/DH_4009546 (accessed 10 April 2008).
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York: The Guilford Press.

 10 Working with
people with eating
disorders
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Renate Pantke and Neil Joughin

PETER’S STORY

My eating disorder developed after a series of difficult and troubling personal events. At
first I was unaware that I was suffering from anorexia. I sought to justify my sudden and
extreme weight loss as something physical, despite my conscious efforts to exercise
and restrict my food intake. As my weight loss accelerated over the course of just a few
months, so too did the intrusive anorexic mindset; a mindset which became so
pervasive that it led to uncomfortable, challenging and overwhelming depressive
thoughts. With time the eating disorder caused me to withdraw from friends and family.
Social experiences induced intense anxiety, especially when involving food, and as a
result it was easier to exclude myself from these occasions rather than face up to my
illness. Gradually, as I became weaker and more alone, I realised that life, as a severely
anorexic male, was no longer a sustainable or desirable future. Faced with increasing
medical evidence from doctors, desperate pleas to seek psychiatric support from my
mother and friends, I began to acknowledge that my life was in immediate danger; my
organs were at risk of failure and my increasing weakness meant that I was unable to
undertake the bare minimum of exertion. I even broke down at the thought of climbing
the stairs for bed, given how weak I had become.

SUMMARY

Eating disorders (EDs) are a fascinating area in which to work, combining complex
interaction of biological, psychological and social issues. However, many professionals
shy away from them perhaps due to the risks they carry or because the skills required
are beyond any one profession’s core training. As a clinical psychologist, the need for
close partnership working with our medical colleagues is essential to good patient care.
 168 RENATE PANTKE AND NEIL JOUGHIN

This chapter has been written by a psychologist (Renate) and a psychiatrist (Neil), and
reflects this partnership approach. We both work with people with severe EDs and
find this task immensely challenging yet equally immensely rewarding. In addition
to this field being academically interesting, clinically the changes we can see in our patients
when they move towards recovery are fantastic, the way in which families mobilise to
fight EDs is inspiring, and the courage and stamina of the greatest majority of our patients
to keep tackling their disorder day-in-day-out for many years, or, at times, decades, is
humbling.
We hope that this chapter will infect you with some of our enthusiasm and interest
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in EDs. It will describe the features or symptoms that are characteristic of eating disorders
and explore how they develop, and the aspects of treatment and management that are
key to helping people recover.

INTRODUCTION: WHAT ARE EATING DISORDERS?

Central to the main EDs is a profound over-evaluation of shape and weight, and the
control of them as a generator and measure of self-worth. In many this over-evaluation
results in major emotional swings between elation and utter despair and terror based
on, for example, whether weight has been gained or lost. This leads to behaviours to
manage calorie intake and expenditure that have a predictable and profound impact
upon a person’s physical and psychological well-being.
In binge eating disorder (BED) and bulimia nervosa (BN), a person may eat a much
larger amount of food in one go than would be regarded as culturally appropriate with
a sense of feeling out of control and associated with negative emotions such as shame
or guilt. This ‘objective binge episode’ may be triggered by interpersonal events and
emotional states (anger, frustration, loneliness, boredom, etc.), or may be a consequence
of a period of starvation. People with BN attempt to compensate for the binge by
vomiting, using laxatives or abusing other medication (e.g. people with Type 1 diabetes
may omit insulin). Others exercise excessively. Most commonly they starve themselves.
These behaviours are extreme and can result in severe physical problems and even death
– without any intention to die.
People with anorexia nervosa (AN) may also binge and/or purge. Often their binge
episodes are more subjective than objective, i.e. a normal-sized meal may be
experienced as an out-of-control binge. Their weight is significantly low for their
height due to insufficient calorie intake and/or excessive exercise as part of an attempt
to lose weight or avoidance of weight gain when already low in weight. People with
AN often have a cognitive style that is very detailed and rigid. The impact of AN is
often described as a ‘starvation syndrome’. The body shuts down, the brain shrinks,
people who may have always been more anxious than most become even more
obsessional, more rigid and less accurate in recognising emotions, etc. Some people
with AN have a distorted body image, i.e. they may perceive themselves as ‘fat’. Others
are ashamed of their emaciation.
Self-esteem issues and heightened anxiety are central to EDs as are issues around
perfectionism, attention to detail, rigidity and often obsessionality (especially in AN).
Often patients with ED also present with low mood or depression perhaps as a conse-
 WORKING WITH EATING DISORDERS 169

Risk
EDs are more likely to result in the death of the patient than any mental
health disorder (Fotios et al., 2009). Of those who die, a significant proportion
dies of suicide. Others die from the direct consequences of malnutrition.
FOCUS 10.1

Importantly, even starting to eat after a period of severe malnutrition may

result in death. While death may be the extreme risk, the list of other risks is
long. Clinical psychologists will have varying roles in managing these risks.
However, no professional involved in managing these patients is absolved
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from the responsibility of knowing how these risks are being addressed. All
care sits under the umbrella of risk management.

quence of living with an isolating and debilitating ED often experienced as shameful

by the sufferer. They often feel as if they are on an emotional roller-coaster, between
numbness in general and extreme emotions when it comes to food or weight. For
many, the ED may be a way of regulating emotions or it may have come to be regarded
as the only way to improve self-esteem and gain a sense of mastery and control,
although at the same time people feel desperately out of control with regard to their
ED. They may have social emotion-processing difficulties which can further add to
isolation. Fearing the judgement and criticism of others, feeling ashamed, or sometimes
superior or special, impacts upon relationships with others with yet more alienation
and isolation.

DIAGNOSIS

The American Diagnostic and Statistical Manual (5th edition) DSM-V describes a
range of eating disorders (ED). We will give you the edited criteria for just two.
Similar disorders that do not fully meet these diagnoses have names such as ‘binge
eating disorder’ (BED) or ‘other specified feeding or eating disorders’ (e.g. atypical
anorexia, etc.).

Anorexia nervosa
A. Restriction of energy intake relative to requirements, leading to a significantly low
body weight.
B. Intense fear of gaining weight or of becoming fat, or persistent behaviour that
interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue
influence of body weight or shape on self-evaluation, or persistent lack of
recognition of the seriousness of the current low body weight.

Specify whether this is restricting type or binge-eating/purging type.

 170 RENATE PANTKE AND NEIL JOUGHIN

Bulimia nervosa
A. Recurrent episodes of binge eating. An episode of binge eating is characterised
by both of the following:
1 Eating, within a discrete period of time (e.g. within any two-hour period),
an amount of food that is definitely larger than what most individuals would
eat during a similar period of time under similar circumstances.
2 A sense of lack of control over eating during the episode (e.g. a feeling that
one cannot stop eating or control what or how much one is eating).
B. Recurrent inappropriate compensatory behaviours in order to prevent weight gain
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such as self-induced vomiting; misuse of laxatives, diuretics or other medications;

fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviours both occur, on
average, at least once a week for three months.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.

Co-morbidity
‘Comorbidity (i.e. having diagnoses other than the ED) is the rule rather than
the exception’ (Treasure et al., 2010). However, there are some that are
particularly important and need to be positively considered within assessment
and management.

• EDs are more common in people with diabetes. Manipulation of insulin

may be used to control weight and thereby the physical risks are greatly
magnified.
• Patients with AN are usually obsessive but also have an increased
likelihood of experiencing symptoms of an obsessive compulsive disorder.
OCD may be a result of starvation and may disappear as the ED improves
but it may also be a problem in its own right.
• Depression may lead to weight loss and low weight in the absence of an
ED. However, depression may also be a trigger for the development of an
ED as well as the result of a debilitating and isolating ED that is often
experienced as shameful by the sufferer.
• Sometimes people with ED meet the diagnostic criteria of emotionally
unstable (or borderline) personality disorder. However, many of the
features seen in EUPD may be related to the ED and may disappear when
the person recovers from their ED. Finding out historical information is
FOCUS 10.2

essential in order to make this differentiation.

• Particularly when seriously underweight, AN patients show a rigidity of
thought and lack of normal emotional responsiveness. This has led to the
thought as to whether AN is a – particularly female – manifestation of
autistic spectrum disorder (ASD) and what may be learned from the ASD
world. Fascinating but as yet inconclusive.
 WORKING WITH EATING DISORDERS 171

EPIDEMIOLOGY OF EATING DISORDERS

Rightly or wrongly, AN is sometimes called an egosyntonic disorder (acceptable to

the person). Therefore people with the syndrome do not all present for help and we
are unclear about how common it is. The incidence has been calculated to be 19 in
100,000 per year in females and two in males, rising to 50 in females aged 13 to 19.
Despite media reports, the evidence for increasing incidence is weak. The lifetime
prevalence of AN in women may be as high as 1.2 to 2.4 per cent. The difference
between the incidence and prevalence is one marker of how commonly the disorder
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can become ‘enduring’. Worryingly, despite the severity of the problem, one study
suggests that only one-third of people with the disorder are in contact with mental
health services.
In community-based studies, the prevalence of BN in young women is usually
quoted as 1 per cent. Again, 90 per cent of people diagnosed are female. Even though
the symptoms are disliked by the person, it is probable that only 8 per cent of sufferers
are in contact with services and wait for very long periods before seeking help. This
reflects shame associated with the symptoms compounded by the poor availability of
services.
AN and BN together are about as common as EDs that do not fit neatly into these
categories (see Diagnosis). For a recent review of these issues see Smink et al. (2012).

AETIOLOGY OF EATING DISORDERS

Since the first descriptions of AN in medical papers in the late nineteenth century by
William Gull (1873) and in Paris by Dr Laségue (1878), different ideas around the
aetiology of EDs have been proposed. Many of these ideas are not supported by current
research evidence. Even the validity of the diagnostic categories of EDs as favoured
by DSM-V is a matter of debate (see ‘Transdiagnostic model’ below).
Like so many other mental health diagnoses, we currently understand that the
development of an ED requires an interaction between a predisposition, environmental
factors and a triggering event. All of these factors would have to be present. No single
factor can be causal. There is evidence to support the biological/genetic predisposition
hypotheses, ranging from heritability studies showing that the more genetically related
a person may be the higher the risk of AN, to observations that people who develop
AN are more likely than others to have a very detailed rigid thinking style and a more
sensitive temperament from very early on in life (Treasure et al., 2010). Intra-uterine
stress, peer group teasing/criticism (especially weight/shape-related) or a family focus
on food, weight and shape have been put forward as environmental factors that may
contribute to a person’s risk of developing an ED.
Most EDs start in adolescence/early adulthood, and are more common in females
than in males. This has led researchers to look at the way puberty affects the developing
brain, especially in the presence of oestrogen. In addition, there are a great many other
developmental challenges during puberty around individuation, separation, physical
and identity development, education, etc. Centrally, weight loss for any reason (e.g.
due to dieting, physical ill health or mental health issues) needs to be present as a trigger.
 172 RENATE PANTKE AND NEIL JOUGHIN

Schmidt and Treasure (2006) wonderfully describe how different factors come
together in the initial phase of weight loss. The person gains a sense of achievement
from their weight loss. This raises their mood and improves their self-esteem. They
are likely to receive compliments from others regarding the weight loss, which further
improves mood and self-esteem, and motivation to continue with weight loss.
For those who develop BN, starvation is followed by an out-of-control binge, and
then compensation for the binge by vomiting or further starvation. All this reinforces
the idea that they will need to control their diet and that weight and shape are essential
in their emotional and interpersonal experience. For those who develop AN, starvation
becomes a greater factor in their life. The ‘starvation syndrome’ becomes a physical
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reality with, for example, a heightened sense of fullness due to delayed stomach
emptying, impaired ability to plan and regulate behaviour in relation to the bigger
picture of the social world and values, increased rigidity, increased preoccupation with
food, extreme emotional experience between numbness of being overwhelmed, and
social isolation as people may become interpersonally less accurate at recognising others’
emotions. Now others become concerned, critical or hostile about the weight loss.
All these consequences of starvation promote and maintain AN.

THEORY AND EVIDENCE FOR PSYCHOLOGICAL INTERVENTIONS

FOR EATING DISORDERS

According to NICE (2004), the National Institute for Health and Care Excellence,
there is moderate evidence for psychological interventions for BN. For AN there is
no gold standard evidence base for any type of intervention, including psychological
therapy, apart from symptom-focused family work in adolescents. However, the lack
of evidence should not deter psychologists from becoming involved with patients with
AN.
The starting point for any psychological intervention is the individual formulation
of the person’s problems, triggers, maintaining factors and their strengths (see Chapter
2). Assessment of their motivation to change is also essential. This formulation then
provides guidance on what kind of psychological intervention may be helpful to the
individual person at that moment in time.
Recovery from an ED needs to address the biological, the emotional, the cognitive
and the interpersonal aspects. Without regular sufficient nutrition a person cannot fully
recover from an ED; hence establishing this is an important part of treatment. We speak
about ‘six a day’ (i.e. three meals and three snacks) trying to ensure regular nutrition
and avoid starvation. People with EDs will struggle with this, and will require psycho-
education and motivational work (Rollnick et al., 2008) in order to understand the
impact of the ED upon their life, what keeps them stuck in it and how they can get
better.
Initial psychological intervention may be around providing engagement, support,
warmth, building trust and may utilise a motivational approach to help the person make
some shifts towards getting better. Very malnourished patients may be helped to
understand their thinking style and try out being more flexible and move towards being
able to see the bigger picture. The problems in managing emotions and relationships
often experienced by people with EDs may also be a useful target for intervention.
 WORKING WITH EATING DISORDERS 173

Early intervention
The concept of ‘early intervention’ has been developed and implemented into
mental health service provision for young people with psychosis across the
UK. Best management at an early point can alter the future course of the
disorder and evidence in ED research suggests that early effective treatment
improves outcome. Complex referral pathways are likely to delay or prevent
patients and their families from arriving at early best care. There are
FOCUS 10.3

arguments for people being able to self-refer to a triage process run by an ED

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service.
A related issue is the likely age at which people are at most risk of
developing schizophrenia or EDs. Service set-up may dictate that patients
have to ‘transition’ their care from adolescent to adult services just as they
are engaging in early treatment. There is an argument for all age services.

Cognitive training may help shift negative attention or interpretation biases to more
positive biases.
Most patients with eating disorders are ambivalent about engaging in treatment at
least at some stage during treatment. The person’s position on the ‘cycle of change’
model (Prochaska and DiClemente, 1982) needs to be kept in mind throughout
therapy, as this is likely to alter and as different motivational stages require a different
response. A person in the ‘ambivalent’ stage may benefit from thinking through the
costs and benefits of change and of staying with the ED, whereas when a person is in
the ‘preparation’ or ‘action’ stage they may require support in goal setting and problem
solving.
Cognitive-behavioural therapy (CBT) has a moderate evidence base for the
treatment of BN and BED. It is best delivered through guided self-help in the first
instance. CBT helps the person challenge their thoughts and make behaviour changes.
CBT-E (enhanced) developed by Chris Fairburn and colleagues for the treatment of
BN and BED additionally tackles ED specific problems such as perfectionism and low
self-esteem. Interpersonal psychotherapy (IPT), which adopts a greater focus on the
relational aspects of a person’s eating disorder, may be equally as helpful as CBT.
However, symptom reduction may take a little longer. In cognitive analytic therapy
(CAT) patients work collaboratively with their therapist to understand how ED
behaviours are embedded in their intra- and interpersonal patterns and coping strategies
that may maintain the ED. Diagrammatic and prose reformulation is used to identify
exits out of unhelpful coping patterns.
Family therapy focused on symptoms of the ED is supported by NICE as a
treatment for adolescents with EDs. Traditionally, this is delivered for individual
families. In the past few years a multi-family therapy approach has found increasing
popularity where a number of families (patients, parents, siblings and others) work
together with professionals. Although there is an absence of evidence base for adults,
severe EDs often leave the person functioning at an emotionally younger age than their
 174 RENATE PANTKE AND NEIL JOUGHIN

chronological age. In addition, many people with severe EDs have to rely on the
ongoing support of their families. Families are usually desperate to help. Hence
helping families develop an understanding of EDs, reduce blame and stigma, and
increase skills to support the person with the ED effectively is an important part of
intervention for the person with the ED and those around them (see indirect work).
It has been shown that carer skills training reduces carer anxiety and depression, and
the behaviours that maintain EDs (Goddard et al., 2011), and there are reports that it
also improves patient outcome.
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CASE STUDY

Aged 22, Anna was pushed by her parents to be referred to mental health services.
She was assessed by our eating disorders team. She attended alone and explained
that for some years she had weighed 7stone 1lb (44.9kg) at a height of 5ft 8in
(1.73m), giving her a body mass index (BMI = weight in kg divided by squared
height in m) of 15. She professed to being pleased with her weight but was worried
that for the preceding year she had been bingeing and vomiting. ‘It’s gross – I’m
gross.’ She said that this loss of control, and the ‘huge’ weight changes, caused her
huge distress. She saw the result as a big drop in her mood and her self-
confidence. She felt overpoweringly guilty and had opted out of social contact with
her friends, feeling that they would also see her as ‘gross’. Her family had been told
that her ‘body salts’, particularly potassium, were very abnormal and might kill her.
They were terrified and had good reason to worry that sudden death was a
possibility. She seemed unconcerned about this risk and said it would be a happy
release. When seen, she said she could see no reason to gain weight but did want
help with stopping the binges.
At age 18 she thinks she weighed 9st 7lb, BMI 20, and had quite liked her body.
She felt lonely across a summer holiday and began to think that she could be more
popular if she lost some weight and took more exercise. She was successful at
this. Those around her initially congratulated her, but others soon began to express
concern that things were going too far. She remained irritated by their concern and
interference.
Our view was that she had developed anorexia nervosa of a binge–purge sub-
type. There was a question as to whether she also had a mood disorder or whether
her mood was in keeping with the building costs of her eating disorder. Her
personality sounded slightly impulsive more than perfectionist, but not markedly so.
Alongside this formulation of her problem we had to include recognition of
elements of malnutrition and worrying potassium problems. All of these problems
needed to be managed.
We decided that it was safe enough to look after her out of an eating disorder
unit provided we had in place a monitoring process, agreed with all, to watch her
weight, her blood chemistry and ECG (electrical heart recording). Admitting such
people to an eating disorder unit is tempting, and at times necessary, because
 WORKING WITH EATING DISORDERS 175

the risks of death are very real. However, the evidence base for admission
helping in this circumstance is poor. There are a number of drawbacks. For
example, admission results in the service taking control of treatment and there
can be difficulties in enabling the patient to take back responsibility for their
condition.
Starting off by recognising that she probably saw it differently, we offered
Anna our initial understanding of her problem but suggested that she meet with a
member of our team to evolve a joint understanding of the mechanisms involved
and how we might help, how she might help herself and how her parents might
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help.
Anna was irritated by the suggestion that her family might be involved, pointing
out that she was an adult. Our response was to underline that, in the end, the
choice was hers, but that we would recommend the involvement of family
whatever the age of the person. We explained that she was not to blame for her
problems, but that neither were her family. However, it was probable that her
family could be helpful if offered support and direction. On the other side, if not
included, there was a risk that their anxiety would make things worse for her.
Her irritation was perhaps enhanced by her own belief that events within her family
were to blame for her eating disorder.
Part of the initial understanding we offered was a psycho-education package
which included the known effects of low weight/starvation on thought and
behaviour and normal eating. For Anna in particular this included the process of low
weight or dietary restriction making bingeing more likely. Anna’s response to the
latter was to minimise this information. She could see the implication of the need
for eating more regularly and gaining weight. Fear of this led to an avoidant
response.
We talked to her about the usefulness of vitamin supplements, potassium
supplementation and the role that FLUOXETINE (an antidepressant that reduces
appetite) might have but suggested that it would be preferable to begin with a
package of psychological care.
Shortly after engaging with us Anna took an overdose and offered a mixed
message of saying that everyone would be better off without her, while also saying
that nobody took her seriously or they would ‘lock me up and stop me stuffing my
face’.
Anna did allow her parents to become involved. They would attend review
meetings as well as the Family and Friends Support Skills Workshop (see below).
With this combination they clearly felt better but the knock-on benefits of less
destructive family anxiety and more understanding had a palpable effect on Anna’s
level of distress.
Individual work blended the input of an eating disorders practitioner (EDP) from
our team and a clinical psychologist. It is not easy to draw clear boundaries for ‘who
is doing what’, but the effects can be synergistic. The EDP provided support,
ongoing psycho-education and ensured safe physical monitoring. The clinical
 176 RENATE PANTKE AND NEIL JOUGHIN

psychologist worked with Anna to develop a shared understanding of the

mechanisms that underpinned her ED based on a bio-psychosocial formulation.
They looked at the behaviours such as restriction and bingeing, identified triggers
and possible alternative coping strategies. It was important to start the work where
Anna felt motivated to make some changes and to get alongside her rather than
pushing her to make changes she was not yet ready to contemplate. They saw that
Anna has always been extremely sensitive to criticism and often perceived criticism
where there was none. Whenever she felt criticised, Anna would feel worthless
and frustrated and this would then trigger a binge. Anna and the psychologist
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worked together to become more aware of this inner critical voice and to challenge
it. Over time, Anna learned how to be more compassionate with herself as well as
with others (the critical voice had also been directed at those around her, especially
her family) and this helped improve Anna’s self-esteem, self-care, and her
relationship with others.
All of the above sat in the context of practitioners who understand the
techniques of motivational interviewing. Through avoiding persistent confrontation
regarding the need for weight gain, Anna herself began to see the necessity for this
if she was going to move out of the increasingly lonely world of her ED. Sadly, she
then made the discovery that she could not eat more and gain weight, and thereby
stop bingeing and vomiting. Her belief had been that she ‘was in control’. Herself
wanting to change these behaviours led her to find out the degree to which the ED
controlled her. ‘It’s an evil illness.’
In concrete terms she could not gain weight. However, she was less blaming of
others which moved her from the counterproductive belief that if others had
behaved differently in the past she would not now have this problem. She had
moved to the more fertile territory of trying to work out what she could change
today. Equally she felt understood, and was being offered a model that did not
blame her for her problems or failure to improve. In this way her self-esteem
improved. Armed with this, she and the professionals were able to look at
tangential approaches to her difficulties. She joined a choir. She went on holiday for
the first time in years. She began to consider re-engaging in education at the point
at which she had left off.
In these circumstances the ‘anorexic voice’ weakened. She was more able to
tolerate weight gain, more able to tolerate ‘fear’ foods and thereby entered a
virtuous circle that eventually enabled her to go off to university to study
psychology. At the point of leaving our service her BMI was still only 17.7 and she
would still occasionally binge and vomit, but she had been helped to recognise
these achievements rather than emphasising what difficulties remained. Her own
perception was that she was now armed with tools she could use without ongoing
professional involvement.
This process took two years and a lot of expert therapeutic input. It required
services to stick with her through a sustained period where she may have been
construed as ‘not trying’.
 WORKING WITH EATING DISORDERS 177

Team working/indirect work

The Family and Friends Support Skills Workshops are based on the Maudsley model
of collaborative care (see Treasure et al., 2007) and offer a blend of education,
training in support skills and support from peers. In the workshop Anna’s parents
learned – to their initial surprise – that they had no direct control over whether their
daughter ate or not, or whether she accepted help or not. What was under their
direct control was their behaviour (e.g. how they looked after themselves, what
beliefs they had about their role in the development of their daughter’s AN and how
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they responded to the AN). Anna’s mother felt that she was the cause of her ED,
that if she had been more sensitive to Anna, Anna would be fine. This belief and the
corresponding guilt resulted in her trying to compensate by doing anything to help
her daughter. This left her exhausted, helpless and even guiltier. On the contrary,
Anna’s father struggled to understand why Anna could not ‘just eat’ and often
became angry at her, and blamed her for the negative impact her behaviour had upon
the family, especially her mother who was close to breaking point. The Maudsley
uses animal metaphors. Mum used this to see how she behaved more like a
kangaroo (over-caring) and Dad more a rhino (angry, pushing for change). The parents
learned that both positions are understandable but neither are helpful. They saw how
they could perhaps work together to help Anna get better and in the workshop they
began practising some skills to support rather than confront Anna and avoid
arguments. Both Mum and Dad felt that they benefited from the workshop. They
joined the monthly support group to continue to meet up with others in a similar
position and share their struggles and achievements.

CRITICAL ISSUES

Trans-diagnostic model
DSM-V is the mainstay of diagnosis but some professionals are critical of this system
(Fairburn and Cooper, 2011). There are two main concerns. First, a significant
proportion of patients do not fit into the main categories. If you believe that diagnosis
should be helpful in informing a management plan, the category of ‘Eating disorder
not otherwise specified’ is not very useful. Second, ED patients do frequently move
between diagnoses. Most commonly restricting AN moves into a more bulimic
picture.

Obesity
For reasons explained in the manual, obesity is not included in the DSM-V as a mental
disorder. Obesity (excess body fat) results from the long-term excess of energy intake
relative to energy expenditure. A range of genetic, physiological, behavioural and
environmental factors that vary across individuals contributes to the development of
obesity; thus, obesity is not considered a mental disorder. In addition, there is the
 178 RENATE PANTKE AND NEIL JOUGHIN

absence of a known mental health problem in obese people and the very limited
evidence for psychological treatments in obesity. It is too easy to think ‘but it must
work’ – despite this lack of evidence.

Starvation syndrome
Chicken or egg? Does abnormal thinking lead to starvation or does starvation create
distorted thinking? The answer is that this is a false dichotomy, but the way in which
starvation changes thinking is too often ignored in the therapeutic process.
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SEVERE AND ENDURING EDS (SEEDS)

Much that is written about EDs focuses on teenage girls. However, people can develop
EDs later in life and teenagers who do not recover grow older. The concept of severe
and enduring eating disorders has therefore been suggested (Robinson, 2009) to
promote modified care models to meet the needs of this group. Overambitious aims
will alienate the patient. There will be a greater need for social and financial support.

ADDICTIONS MODELS

It is hard to escape parallels to the world of substance misuse. As a consequence useful

concepts such as ‘Stages of Change’ and motivational interviewing have crossed over
to the ED world (Prochaska and DiClemente, 1982; Rollnick et al., 2008). Despite
the usefulness it is important to recognise where parallels break down. An example
would be the major and early advantages of detoxification from alcohol versus the
sustained distress of someone with AN endeavouring to gain weight.

Capacity
A proportion of patients with AN will have a long-term life-ruining illness that has
not responded to extensive treatment. Treatment, particularly admission, may be
experienced as abusive. Can such patients ever legally refuse life-saving treatment? The
current answer is that we do not know, but any such examples will be very rare. The
Mental Capacity Act (MCA) gives us a framework for addressing these issues (MCA,
2005; and Tan, 2006, 2012).

CONCLUSION

We hope that we have conveyed the sense that EDs are severe illnesses which can
ruin lives but that, while distressing, they provide an interesting and fulfilling area in
which to work. It is both anxiety provoking and stimulating to work where there is
so much that we do not understand. The management of EDs shows how you cannot
extrapolate from effective treatments to cause. For example, we are sure that family
dynamics do not cause AN. However, working with the family is our most effective
intervention. Uncertainty about cause does not prevent us from helping.
 WORKING WITH EATING DISORDERS 179

CONCLUSION TO PETER’S STORY

While anorexia nervosa nearly beat me, I have managed to fully recover from my eating
disorder. Successful holistic therapy proved invaluable in enabling me to confront and
overcome my anorexia. Through a combination of talking therapies, nutritional
counselling, antidepressants and a close monitoring of my physical health, the team
supporting me helped me transform my future. While sceptical of the value of
antidepressants and talking therapies at first, my experience leads me to conclude that
these options were critical to my achieving a recovery. I was fortunate to receive
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excellent medical attention, but the key for me, and other patients whom I encountered,
was to acknowledge one’s own difficulties and confront these head-on. While fiercely
independent, I had to learn to accept the help of others. This was by no means a
weakness and now I take great comfort in reaching out and seeking support from those
who are closest to me. While recovery was a difficult journey, it was most certainly the
right course of action upon which to embark.

KEY CONCEPTS AND TERMS

• Anorexia nervosa • BMI • NICE

• Bulimia nervosa • Motivational • Starvation syndrome
• Severe and enduring interviewing • Capacity
EDs • Family and Friends
• DSM-V Support Skills
• Trans-diagnostic Workshop
model

LEARNING OUTCOMES

When you have completed this chapter you should be able to:

1. Recognise what features or symptoms are characteristic of anorexia nervosa,

bulimia nervosa and other similar types of eating disorders.
2. Have an understanding of the types of psychological difficulties suffered by
people with these EDs.
3. Have an understanding of the current evidence base for psychological treatment
of these EDs.
4. Have an understanding of the aspects of treatment and management that are
likely to be important during the course of the ED.
5. Have an understanding of how clinical psychologists work together with other
professions to assess, formulate and treat EDs.
 180 RENATE PANTKE AND NEIL JOUGHIN

SAMPLE ESSAY TITLES

• What are the important aspects of psychological treatment in EDs?

• When assessing for EDs what factors need to be taken into account?
• What are the areas in need of further research in EDs?
• How do psychologists work together with other professions to help people with
EDs?
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REFERENCES AND RECOMMENDED READING

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders
(5th edn). Arlington, VA: American Psychiatric Publishing.
beat – the leading UK charity for people with eating disorders and their families – a very good
source of information and useful contact numbers. Available at www.b-eat.co.uk.
BEAT and ProBono Economics Report (2012). Costs of eating disorders in England: Economic
impacts of anorexia nervosa, bulimia nervosa and other disorders, focussing on young
people. BEAT.
Bryant-Waugh, R. and Lask, B. (2004). Eating Disorders: A parents’ guide. Hove, Sussex:
Brunner-Routledge.
Cooper, P.J. (1993).Overcoming Bulimia and Binge-eating. Robinson Publishing.
Fairburn, C.G. (1995). Overcoming Binge Eating. New York: The Guilford Press.
––– (2008). Cognitive Behaviour Therapy and Eating Disorders. New York: The Guilford Press.
Fairburn, C.G. and Cooper, Z. (2011). Eating disorders, DSM–5 and clinical reality. The British
Journal of Psychiatry, 198, 8–10.
Fotios, C., Papadopoulos, A.E., Brandt, L. and Ekselius, L. (2009). Excess mortality, causes of
death and prognostic factors in anorexia nervosa. The British Journal of Psychiatry, 194, 10–17.
Garner, D.M. (1997). Psychoeducational principles in the treatment of eating disorders. In D.M.
Garner and P.E. Garfinkel (eds), Handbook for Treatment of Eating Disorders (pp. 145–177).
New York: The Guilford Press.
Goddard, E., Macdonald, P. and Treasure, J. (2011). An examination of the impact of the
Maudsley Collaborative Care Skills Training Workshops on patients with anorexia nervosa:
A qualitative study. European Eating Disorders Review, 19, 150–161.
Institute of Psychiatry; Eating Disorders Research Site – as described it contains a lot of useful materials
for professionals, families and patients. Available at www.eatingresearch.com.
Mental Capacity Act (MCA) (2005). Available at http://www.dca.gov.uk/menincap/legis.htm
Mental Health Act (2007). Available at http://www.legislation.gov.uk/ukpga/2007/12/
pdfs/ukpga_20070012_en.pdf.
National Institute for Health and Care Excellence (NICE) (2004 and 2011). Eating Disorders
CG009. London: National Institute for Health and Care Excellence.
Prochaska, J.O. and DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more
integrative model of change. Psychotherapy: Theory, Research and Practice, 19(3), 276–288.
 WORKING WITH EATING DISORDERS 181

Robinson, P. (2009). Severe and Enduring Eating Disorder (SEED): Management of complex
presentations of anorexia and bulimia nervosa. Oxford: Wiley-Blackwell.
Rollnick, S., Miller, W.R. and, Butler, C.C. (2008). Motivational Interviewing in Health Care:
Helping patients change behaviour. New York: The Guilford Press.
Royal College of Psychiatrists website – a source of basic information about eating disorders.
Available at www.rcpsych.ac.uk/mentalhealthinformation.aspx.
Schmidt, U. and Treasure, J. (1993).Getting Better Bit(e) by Bit(e). Hove, Sussex: Psychology
Press.
Schmidt, U. and Treasure, J. (2006). Anorexia nervosa: Valued and visible. A cognitive-
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interpersonal maintenance model and its implications for research and practise. British Journal
of Clinical Psychology, 45(3), 343–366.
Smink, F.R.E., van Hoeken, D. and Hoek, H.W. (2012). Epidemiology of eating disorders:
Incidence, prevalence and mortality rates. Current Psychiatry Reports, 14, 406–414.
Tan, J. (2012). Royal College of Psychiatry EDSECT Newsletter. December.
Tan, J., Stewart, A., Fitzpatrick, R., and Hope, R.A. (2006) Competence to make treatment
decisions in anorexia nervosa: Thinking processes and values philosophy. Psychiatry, and
Psychology, 13(4), 267–282.
Treasure, J. (1997). Anorexia Nervosa; A Survival Guide for Families, Friends and Sufferers. Hove,
Sussex: Psychology Press.
Treasure, J., Smith, G. and Crane, A. (2007). Skills-based Learning for Caring for a Loved One
with an Eating Disorder. Abingdon, Oxon: Routledge.
Treasure, J., Claudino, A.M. and Zucker, N. (2010) Eating disorders. Lancet, 375, 583–593.
Waller, G., Mountford, V., Lawson, R., Gray, E., Cordery, C. and Hinrichsen, H. (2010).
Beating Your Eating Disorder: A cognitive-behavioural self-help guide for adult sufferers and their
carers. Cambridge: Cambridge University Press.
 11 Working with
people with PTSD
and complex trauma
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Maeve Crowley and Ines Santos

PETER’S STORY

I am a 35-year-old man, living with my partner and three sons aged between 5 and 11.
I am unemployed but previously worked as a plumber. I am one of seven children.
My father was a builder and he drank too much and used to beat up us kids. My mother
struggled to cope. Life was tough but that’s how it was.
Ten years ago after a pub brawl I was beaten and left for dead outside a pub.
Following the attack, my physical recovery from a broken collar bone and broken ribs
was slow. From that day on, I lost my confidence and was scared of going out in case I
was attacked again as the attackers were never caught; scared that I would lose my rag
and end up in prison. I started getting panic attacks and getting easily upset by noise,
spending most of the time in my room on my own. I was unable to stop thinking about
the beating and it played in my mind almost constantly like a film. Sometimes, I went
crazy, I lost the sense of where I was and it felt like the assault was happening all over
again – the footsteps behind me, the whack on my head, the sense of falling on my face
thinking ‘This is it, I’m in for it’. I started smoking cannabis because that was the only
way to numb my feelings and get me to sleep but I woke soon after with nightmares of
being chased and would wake up shouting and soaked in sweat. My partner got scared
when I woke up like that at night.
Ten years on and little has changed. I’m stuck in a rut and don’t know how to get out.
My life is worthless. I’m a failure for letting this get on top of me. I am failing my
partner, I am failing my children. I sometimes wonder if they would be all better off
without me.
 WORKING WITH PTSD AND COMPLEX TRAUMA 183

SUMMARY

In a world where trauma is commonplace, in the form of natural disasters, wars, accidents,
violence and abuse, it is important to understand people’s reactions to these events and
to develop effective clinical treatments. Alongside depression and anxiety, the most
common psychological reactions to trauma are post-traumatic stress disorder (PTSD) and
complex PTSD (C-PTSD).
Treatment for traumatic stress disorders has a long historical tradition and as early
as the First World War soldiers were diagnosed with ‘shell-shock’. Early treatments
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were primitive, based on repressing the memories and experiences (Jones and Wessley,
2006). Our knowledge about PTSD and how to treat it has developed considerably
since then.
In this chapter we hope to give you an insight into the experience of having PTSD
and C-PTSD, how it can be assessed and treated clinically and also a sense of traumatised
individuals’ tremendous capacity to heal and grow from their experiences. We also want
to give you a sense of how deeply rewarding it can be to work with this client group.
We will review some of the psychological theories and models that are relevant to PTSD
and complex PTSD and look at how assessment, formulation and intervention techniques
are used by psychologists working with traumatised individuals. We will also be
highlighting some of the controversies in the field of traumatology and their scientific and
clinical implications.

INTRODUCTION: WHAT IS PTSD AND COMPLEX PTSD,

AND WHAT ARE THE TYPES OF PSYCHOLOGICAL DIFFICULTIES
THAT CAN OCCUR IN THESE DISORDERS?

PTSD
PTSD can occur as a consequence of exposure to exceptionally threatening and
distressing events, such as natural disasters, car crashes, sexual assaults, terrorist attacks
or war.
A very disturbing feature of PTSD is intrusive memories of the trauma. These
memories are accompanied by images, smells and bodily sensations that were
experienced at the time of the trauma.
Reminders of the trauma, such as hearing a car braking, lead to intense and
prolonged distress (e.g. fear, shame) and are accompanied by physical anxiety similar
to a panic reaction.
Sometimes, the person feels as if they are actually reliving the trauma and this is
known as a flashback. Flashbacks can be very distressing and people can feel that they
are going mad, as they do not understand what is happening to them.
Intrusive memories of the trauma can occur during sleep in the form of nightmares.
These intrusive symptoms keep the trauma and the sense of danger very much in the
present and thus these individuals are chronically aroused, constantly on the alert for
 184 MAEVE CROWLEY AND INES SANTOS

danger (hyper-vigilance). They also startle easily, for example, if there is an unexpected
knock at the door. This high level of arousal leads to problems in concentration and
sleep, and to people being more irritable and aggressive.
In an attempt to cope with these overwhelming symptoms individuals develop
avoidance strategies. For example, people may avoid driving, going out at night or
certain television programmes. Avoiding talking about the trauma can make it difficult
for people to seek treatment or to give an account of the trauma, for example, to police
or lawyers.
Difficulties in mood regulation may include emotional numbing and detachment
from others and the world. In addition, they may have negative views of themselves,
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others and the world, for example, ‘I am unlucky’ and ‘I attract bad people’.
As we can see from this list of symptoms, the effects of PTSD can be far-reaching
and have a debilitating impact upon many areas of a person’s life such as mental and
physical health, relationships, work and school.

Complex PTSD
Complex PTSD was first proposed as a condition by Herman (1992), who observed
that exposure to traumas such as prolonged abuse (domestic violence), organised abuse
(paedophile gangs, trafficking or torture) was associated with a particular set of clinical
symptoms beyond and including those for PTSD. People found it difficult to manage
their emotions and urges, sometimes presenting with violent outbursts. Other times
they have a tendency towards dissociating when under stress, for example, losing time,
seeing themselves as existing outside their bodies, or forgetting important aspects of
their past. They often see themselves as worthless, unlovable and weak, and often
experience feelings of shame and guilt about what they experienced, witnessed or could
not stop. As they were abandoned or betrayed as children they can have difficulty
trusting people or find it hard to judge who is trustworthy.
Clients with C-PTSD will often be mislabelled and misunderstood, and so find it
hard to access appropriate help.

Diagnosis of PTSD
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard
classification of mental disorders used by mental health professionals, and lists which
symptoms must be present for each disorder.
DSM-V (APA, 2013) diagnostic criteria for PTSD requires a history of exposure
to a traumatic event involving death, threatened death, actual or threatened serious
injury, or actual or threatened sexual violence. In addition, symptoms from each of
four symptom clusters must be present:

• Intrusion (memories, nightmares, flashbacks, emotional distress and physical

anxiety to traumatic reminders) (one symptom required).
• Avoidance (avoidance of thoughts or feelings as well as people, places, conver-
sations, activities, objects or situations related to trauma) (one symptom required).
• Negative alterations in cognitions and mood (two symptoms required).
• Alterations in arousal and reactivity (two symptoms required).
 WORKING WITH PTSD AND COMPLEX TRAUMA 185

Symptoms must continue for more than one month and cause significant distress and
impairment. There is a sub-type of PTSD with dissociative symptoms (depersonal-
isation or de-realisation) and also a delayed onset sub-type.

Additional symptoms in complex PTSD (Herman, 1992)

An individual who has experienced a prolonged period (months to years) of chronic
victimisation and total control by another may also experience difficulties in the
following areas:
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• Emotional regulation (e.g. persistent sadness, suicidal thoughts, explosive anger).

• Consciousness (e.g. having episodes in which one feels detached from one’s mental
processes or body – dissociation).
• Self-perception (e.g. a sense of being completely different from other human
beings).
• Distorted perceptions of the perpetrator (e.g. attributing total power to the perpetrator).
• Relations with others (e.g. isolation, distrust).
• One’s system of meanings (e.g. a sense of hopelessness and despair).

Complex PTSD is not yet a formal psychiatric diagnosis but it is a well-recognised

clinical condition. It seems likely that it will be included in the new ICD-11. The
symptom pattern being proposed is the core symptoms of PTSD plus persistent and
pervasive impairments in affective functioning, self-functioning and relational
functioning.

EPIDEMIOLOGY OF PTSD

Epidemiological research of traumatic events in PTSD reveals a number of important

points.
First, surveys (e.g. Kessler et al., 1995) reveal that traumatic events are common,
with most people (around 60%) experiencing at least one major traumatic event in
their life and most having exposure to multiple traumas. Exposure to traumatic events
is somewhat higher for men than for women.
Second, these surveys reveal that most people exposed to trauma do not develop
PTSD, symptoms developing in only about 10 per cent of cases, suggesting that
individual factors play an important role in the aetiology of the disorder.
Third, although only a minority develop PTSD, it is nevertheless a high prevalence
disorder, with 7.8 per cent of people having a lifetime history of PTSD, with women
twice as likely as men being affected.
Fourth, PTSD tends to be of a chronic nature and requires professional treatment,
with a significant minority not recovering even with treatment (NICE, 2005).
Thus, given that only a minority of people develop PTSD after exposure to trauma,
what factors determine which people develop the disorder and which do not?
Well, research suggests that it depends on factors such as characteristics of the
traumatic events as well as individual risk factors. Rape has the highest trauma impact,
 186 MAEVE CROWLEY AND INES SANTOS

with other high-impact events including combat stress, childhood neglect and
childhood physical abuse, and physical assaults. Of the individual risk factors, psychiatric
history, childhood abuse and family psychiatric history are reliably found to be risk
factors for PTSD (Brewin et al., 2000). Cognitive appraisals (i.e. the sense a person
makes of the trauma, at the time of trauma and in its aftermath) have also been found
to be important predictors of PTSD.

AETIOLOGY OF PTSD
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The reasons why someone reacts to a trauma and develops PTSD or C-PTSD are
varied, but an understanding of the evolutionary biological basis is essential. A person
perceives a threat. It is registered in the part of the brain that is there to raise the alarm
(the Amygdala). The system is aroused and prepares for the fight-or-flight response.
If this is not possible the body freezes. The neurochemicals released close down the
activity of the thinking brain (neocortex) and cortisol shuts down the hippocampus.
This means that the experience cannot be processed, time tagged or stored, and as a
result may be re-experienced sometime in the future.
Unfortunately, if a trauma memory is not processed it may be re-experienced in a
number of ways in the form of intrusions, and this leads to avoidance. This re-triggering
is outside the person’s conscious control. People who have experienced abuse describe
being triggered by certain smells or a look on someone’s face and then react as if the
past trauma is occurring in the present.
Despite the neurological basis of trauma being central, we also know that different
people respond differently to different traumas depending on the resources available
to them. For example, a person who has a good experience of parenting (a secure
attachment) will manage the effects of a trauma more effectively. People with more
effective coping resources, people with greater social support and people without a
history of early trauma are more likely to cope better with traumas experienced in
adult life.

PSYCHOLOGICAL INTERVENTIONS FOR PTSD

How can an individual be helped to come to terms with a traumatic event? Does
trauma therapy really work and what is it like?
In 2005, the NICE (National Institute of Health and Care Excellence) guidelines
for treatment for PTSD were published, concluding that trauma-focused cognitive-
behavioural therapy (TF-CBT) and eye movement desensitisation and reprocessing
(EMDR) are equally effective in the treatment of PTSD and should be offered to all
people with PTSD (NICE, 2005).
The fact that these treatments involve some degree of retelling of the trauma
narrative is what makes them more effective than other treatments such as relaxation
or supportive therapies.
Trauma therapy, like therapy for other conditions, starts with a comprehensive
assessment and psycho-education about trauma and trauma symptoms alongside the
development of a strong therapeutic relationship.
 WORKING WITH PTSD AND COMPLEX TRAUMA 187

Trauma-focused CBT
An important element of TF-CBT is exposure to the trauma. There are two types of
exposure:

• Imaginal exposure: Patients are asked to give a detailed account of the trauma
narrative in the present tense, including sights, sounds, smells, emotions and bodily
sensations. This is called ‘reliving’.
• In vivo exposure: This involves exposure to the actual site and triggers of the trauma.
Patients may go to the place where the assault happened or to the site of the car
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crash.

Exposure is hypothesised to lead to an elaboration of the trauma memories, where

they become more complete and include extra details, such as ‘I could not have seen
the car coming because I can’t see round corners’ or even ‘I survived, it’s in the past’.
Some TF-CBT treatments, such as prolonged exposure therapy, have their main focus
on exposure, and have been shown to be very effective, for example, with rape victims
(Rothbaum et al., 1992).
With other CBT approaches, such as cognitive processing therapy, the focus of therapy
is cognitive restructuring; that is, changing how an individual views themselves, the
trauma and its consequences (Resick and Schnicke, 1993).
However, most trauma-focused cognitive-behavioural therapies incorporate both
exposure and cognitive restructuring. Ehlers and Clark’s Cognitive Model of PTSD
(Ehlers and Clark, 2000) is the evidence-based CBT model for PTSD. The total
duration of TF-CBT therapy is between eight and 20 sessions.
PTSD and CBT (videos)
http://www.youtube.com/watch?v=Tx3KdKDZOS8&list=PLuEO9Uf2A6CXs9J5G
1qwvtB8JzZ_Uk1aP.

Eye movement desensitisation and reprocessing (EMDR)

EMDR therapy is based on the Adaptive Information Processing Model (Shapiro,
2001). It postulates that the physiological systems of the brain are no different from
body systems. It has a natural tendency to heal and process following a trauma unless
there is repeated traumatisation or a block to that healing – as evidenced by the fact
that most people do not develop PTSD after exposure to trauma.
According to Shapiro, there is a natural physiological system that is designed to
transform disturbing input into an adaptive resolution and a psychologically healthy
integration. It will just file it away in the appropriate folder. If there is a blockage in
this information processing, it will react to the present as if the individual is in the
past, thus experiencing it again. As they are frozen in the past, they cannot freely
experience the present. The brain does not discard the maladaptive material and
therefore cannot access more adaptive material from the present.
Imagine the exhaustion of constantly experiencing the danger of the past, while
trying to experience the present. One can see how it is hard for traumatised people
to gain pleasure from good things in the present (family, hobbies, etc.) when there is
 188 MAEVE CROWLEY AND INES SANTOS

a movie of the trauma running in the background, often more vivid in response to
reminders.
EMDR accesses the target trauma memory and all its emotions, thoughts and
physical sensations. As the client has dual attention both on the past memory and the
current safety, they process the unprocessed memory and access more adaptive
memory networks. This is achieved through bilateral stimulation, activating both
hemispheres of the brain, through following the therapist’s hand moving from side to
side, listening to bilateral sounds, or having bilateral tappers in one’s hands.
Getting Past Your Past/Francine Shapiro
YouTube: https://www.youtube.com/watch?v=nylajeG6uFY
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Treatments for complex PTSD

The NICE guidelines focused upon PTSD and not upon complex PTSD,
acknowledging that individuals who suffered multiple and chronic traumas would
need more extensive and comprehensive treatment than that recommended for simple
PTSD (NICE, 2005).
For C-PTSD a three-phased approach to treatment involving stabilisation, trauma
processing and reintegration is increasingly regarded as the best approach (Cloitre
et al., 2012).

• Phase 1: Establishing safety and stability, reducing symptoms and increasing

important emotional, social and psychological competencies.
• Phase 2: Processing unresolved trauma memories so that they are integrated into
the adaptive representation of self, relationships and the world.
• Phase 3: Consolidation of treatment gains to facilitate transition from the end of
treatment to greater engagement with the outside world.

These three phases may be achieved using various evidence-based trauma therapies
(EMDR and CBT) and supplemented with other psychological techniques as required.

CASE STUDY 1: TINA

Tina is a 33-year-old woman who was referred to mental health services following a
sexual assault in a pub. She presented with severe depression, symptoms of trauma
and was at high risk of suicide.

Assessment with a clinical psychologist trauma

specialist
Tina had a history of childhood trauma characterised by poor attachments (including
separations from both parents at various times and the witnessing of severe
domestic violence). She experiences further poor and violent relationships in
adulthood.
 WORKING WITH PTSD AND COMPLEX TRAUMA 189

Assessment revealed severe trauma symptoms following a recent sexual assault,

supported by high scores on the Impact of Events Scale Revised (IES-R), and there
was evidence of high levels of dissociation, supported by high scores on the
Dissociative Experiences Scale (DES).
She reported avoiding going out by herself, which seemed to be due to fears
about being attacked again. This was severely affecting her daily functioning, and her
ability to continue studying and seek work.
The conclusion from the assessment was that she needed specialist trauma
therapy.
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Formulation
As the therapist was an EMDR practitioner, this case was formulated using AIP
(adaptive information processing).
We hypothesised that unprocessed childhood traumas were reactivated by adult
traumas and in particular the recent sexual assault. The sexual attack triggered her
feelings of fear, shame and inability to trust others, which were similar to earlier
traumatic experiences. The fear network was activated and it generalised to other
situations, making her unable to leave the house and function normally.
The goal of therapy was to help her process the past traumas so that she could
feel safe again in the present and be able to access more adaptive memory networks
and ways of being, such that she had survived, that she was safe and that others
could be trustworthy.

Trauma therapy
Tina was treated with EMDR, but trauma-focused CBT would also have been another
treatment of choice.
The first phase of trauma therapy is stabilisation. As is always done at the
beginning of an EMDR treatment, we developed a calm place, a visualisation of an
imagined place – in Tina’s case a tropical beach – where she could feel calm, leading
to a felt sense of calm and reduced arousal and anxiety. We installed this using
bilateral stimulation (in this case through the use of slow eye movements).
The stabilisation was strengthened using Resource Installation, which is an EMDR
approach to develop and enhance internal coping in clients with complex
presentations and poor emotional regulation skills. We did some work on enabling
her to access positive memories – being competent in work situations, being a good
mother, feeling safe with her grandfather, again reinforcing this using bilateral
stimulation. This resource work enhanced her self-confidence and confidence in her
ability to master challenging situations.
The initial focus of trauma processing was the sexual assault, as Tina was clear it
was what she wanted to work on and she did not want to delve into the past.
Processing of the sexual assault was done over three sessions. She focused on
the worst moment of the assault, the negative belief ‘It’s my fault’ and the
 190 MAEVE CROWLEY AND INES SANTOS

sensations in her body, and tracked the therapist’s fingers left and right. She then
reported what had come up (e.g. ‘I can see him coming towards me and I feel sick’)
and the processing continued for another set, before further feedback was given.
Tina accessed the full memory of the assault and how she felt, and experienced a
fuller recall, including the fact that she pushed him away, that she got help, that
others were sympathetic and helpful, and that the attacker had left the country so
she was safe.
Her negative belief of ‘It’s my fault’ changed to ‘I did the best I could’ and the
Subjective Units of Distress (SUDS) reduced from 9/10 to 0/10. She reported that she
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was no longer disturbed by the memory.

However, she was still afraid to go out. From an AIP perspective this was to be
predicted, since the underlying early memories had not been processed. This
formulation was again shared with Tina and at this point she was more willing to
explore her past.
We were able to identify that a belief that ‘I am disgusting’ and a high sense of
shame, as well as fear, was underlying her avoidance of going out. Using a
‘Floatback’ technique, we tracked these feelings to early experiences of being
treated sexually inappropriately by a step-parent. She had come to blame herself for
this and strived to be invisible to keep herself safe. This sexual abuse was in the
context of her witnessing severe domestic violence and fearing for her life as well as
for the life of her mother and younger sister.
Tina reported that she had not made the link between those traumatic
experiences and her current view of herself and her fear of going out.
Using EMDR, we were able to process these earlier traumatic memories and to
shift beliefs of ‘I am disgusting’ and ‘I am to blame’. The fear of going out improved,
as did the dissociation.
In conclusion, Tina presented with PTSD but in the context of more global C-
PTSD. The trauma intervention in this case was EMDR, and involved processing both
recent and earlier traumas (sexual abuse, witnessing domestic violence) as these
were underlying the current difficulties.
Alongside trauma therapy, Tina was seen regularly by her psychiatrist who took on
a very important supportive role, monitored risk on an ongoing basis and enabled her
to get on with day-to-day life.
Working alongside another professional who is taking a care coordinating role
significantly facilitates the clinical psychologist’s role, enabling them to focus on
being a therapist as opposed to continuously having to monitor day-to-day functioning
and risk, sorting out benefits and liaising with GPs about medical issues.

CASE STUDY 2: LONDON BOMBINGS – A PUBLIC MENTAL

HEALTH STRATEGY

On a Thursday morning, 7 July 2005, London was struck by four suicide bombers.
Just before nine o’clock, still in rush hour, three bombs went off on underground
 WORKING WITH PTSD AND COMPLEX TRAUMA 191

trains. An hour later the final explosion went off on a double-decker bus. The
coordinated attacks killed 52 people and injured more than 770 (BBC News
website).
Many of us will remember forever that morning of 7/7, hearing and seeing the
unbelievable news. The psychological effect on the population of London was
substantial, with about one-third reporting substantial stress, and another one-third
reporting fear of travelling on public transport (Rubin et al., 2007). Seven months
later, this stress had reduced significantly, though a more negative worldview was
common. A significant minority who suffered greater exposure to the bombings
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remained affected.
The public mental health strategy adopted was to systematically locate and screen
individuals directly affected by the bombings and to offer trauma treatment to those
in need (Brewin et al., 2010). Contact details of individuals involved in the bombings
were obtained from sources such as local NHS services, charities, police, as well as
contacting GPs and through a media campaign. The individuals identified were given
a screening assessment, including the specially developed Trauma Screening
Questionnaire (TSQ) either by letter or phone.
People who scored positive on the screening were invited for a more detailed
clinical assessment, to determine whether they had traumatic symptoms that were
not resolving on their own. People were referred immediately to treatment or
monitored for natural recovery and reassessed at three, six and nine months. In
accordance with NICE guidelines, two trauma treatments were offered – TF-CBT or
EMDR – across three London trauma services.
Brewin et al. (2010) report that in total, 910 people were identified through the
Trauma Response Programme as having been directly affected by the terrorist
attacks but, given that no official figures exist, many more people could have been
affected and remain with unmet needs.
A total of 596 people returned screening questionnaires, of which 57 per cent
screened positive and were clinically assessed. The most common diagnosis was
PTSD, and almost half had other psychological disorders, including travel phobia,
depression and complicated grief.
A total of 304 people (41% of those screened) were found to be in need of
treatment. Some did not want therapy and some were referred for therapy near their
home, so 248 were taken on for treatment in the programme, of whom 189
completed treatment. The average number of sessions was 12, with some patients
receiving as many as 59 sessions. Those requiring greater numbers of sessions had
often suffered also from previous prior traumas.
Results showed that therapy led to significant improvement in symptoms of
trauma and depression, and these improvements were maintained one year post-
treatment.
 192 MAEVE CROWLEY AND INES SANTOS

CRITICAL ISSUES

Dissociation
We all dissociate to a certain extent. We cannot take in every experience around us,
but there is a difference between daydreaming through a lecture and losing time from
finding yourself in a situation while not knowing how you got there. This is very
frightening, overwhelming and risky, especially if you are reliving a traumatic memory.
In their excellent self-help book Coping with Trauma Related Dissociation, Boon and
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colleagues (2011) state:

Dissociation develops when an experience is too threatening or overwhelming

for a person to integrate it. It’s spontaneous and adaptive and subsides when the
danger has passed. This inability to integrate our traumatic experiences changes
our sense of self and our personality.

Van der Hart and colleagues (2006) hypothesise that severe trauma can split the
personality into characteristic parts: an apparently normal part (ANP) that continues
to adapt to the demands of daily living (working, looking after a family) and an
emotional part (EP) that holds the experience of the trauma in the form of reliving
(intrusions in the here and now). There is usually a phobic avoidance of the trauma
memory held by the EP; hence the need to dissociate. The person who dissociates to
this extent is usually frightened and overwhelmed by this experience.
Treatment focuses on first recognising dissociation and learning to stabilise oneself,
managing symptoms and keeping oneself safe. Only then can the client go on to process
the trauma.

False memory
A false memory is a mental experience that is mistakenly taken to be a true
representation of an event from one’s personal past. False memories arise from the same
encoding, rehearsal and memory attribution processes that produce true memories;
some indeed argue that one can never be absolutely sure of the truth of any particular
memory.
We know that child sexual abuse is a major societal problem (as evidenced by the
high-profile cases in the UK), and children often do not disclose abuse unless
specifically asked. The dilemma for applied psychologists and psychological therapists
is that we have to balance the need to ask about experiences of childhood trauma,
including abuse, in a manner that limits the danger of creating false memories. The
British Psychological Society’s guidelines are useful to consider in this area (Wright
et al., 2006).

Vicarious trauma and burn-out

If you are privileged enough to work with trauma survivors there is a danger that you
hear so many distressing and truly traumatic stories that it has a significant effect upon
 WORKING WITH PTSD AND COMPLEX TRAUMA 193

your own well-being. Pearlman (1999) described vicarious traumatisation as the

process of how the client’s graphic and painful material challenges our cognitive
schemas or beliefs, expectations and assumptions about ourselves and others. Through
supervision and ensuring we have enriching experiences outside work we can limit
the effect of vicarious traumatisation while also marvelling at how people strive to
overcome the horrors of traumatic experiences.

Broadening the definition of trauma

There is controversy over the broadening of the definition of trauma, with increasingly
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more of everyday life being included in the definition of traumatic. McNally (2003)
argues that it imposes a medical model upon the human experience while trivialising
genuinely traumatic events, and this may shape our culture in ways that undermine
our capacity for resilience in the face of adversity. This controversy has been highlighted
in the recent changes to DSM-V and the proposed changes to ICD-11.

CONCLUSION

PTSD can be a very disabling and at times chronic condition. Fortunately, once people
ask for help, there are two effective evidence-based psychological therapies that are
available to help people with the condition. Getting access to help can be difficult,
particularly if people are feeling ashamed or if people struggle to come to terms with
what they believe will be the implications of asking for help (e.g. members of
military). Fortunately, we are now being much more proactive in our attempts to
engage people with PTSD in our services to overcome the effects of trauma.

PETER’S STORY: CONCLUSION

My partner saw a programme on TV about PTSD, nightmares and flashbacks and told
me that’s what I had. She took me to our GP who referred me to a psychology service. I
met with a clinical psychologist who spent two hours asking me all sorts of questions
and in the end agreed that I had PTSD and gave me the first good news I’d had in years:
it was treatable.
I had treatment with EMDR – about 30 sessions of an hour and a half on a weekly
basis. It was hard-going initially as I wasn’t used to talking about myself and my
feelings, it just wasn’t how I was brought up. It felt odd. We worked through the assault
and the memory changed. It felt more distant, I focused on the fact that I’d survived,
that I’d been lucky rather than unlucky. We talked about my childhood and worked
through some childhood memories, of being beaten at home and at school, of being
humiliated, of having to use my fists to protect myself.
I’ve stopped smoking cannabis. I spend time with the children and take them to
school. I go shopping with my partner. Best of all, I can think through situations now and
trust myself to make the right decisions.
 194 MAEVE CROWLEY AND INES SANTOS

KEY CONCEPTS AND TERMS

• Fight, flight and • Adaptive information • Hotspots

freeze response processing • Attachment
• Intrusions, avoidance, • EMDR • Vicarious
hyper-arousal • Targets traumatisation and
• Dissociation • Bilateral stimulation burn-out
• Triggers • Reliving
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LEARNING OUTCOMES

When you have completed this chapter you should be able to:

1 Know what features or symptoms are characteristic of PTSD and complex PTSD
and to have an awareness of the types of psychological difficulties suffered by
people who have experienced these symptoms as the result of exposure to a
trauma stressor.
2 Have an understanding of the psychological and societal impact of trauma upon
the individual.
3 Have an understanding of the psychological theories or models that are relevant
to PTSD and complex PTSD.
4 Have an understanding of the treatment approaches used by clinical
psychologists to treat the condition – and the evidence base for these.
5 Have an understanding of how assessment, formulation, intervention and
evaluation may be used in a psychologist’s work with a specific case.
6 Be able to provide a critical appraisal of the different intervention approaches.

SAMPLE ESSAY TITLES

• What are the factors that impact upon people’s processing of a traumatic event?
• What differentiates the theories of PTSD and what do they have in common?
• What issues would you consider when deciding to use either CBT or EMDR?
• What are the current controversies around the diagnosis of PTSD?

FURTHER READING

Briere, J. and Scott, C. (2012). Principles of Trauma Therapy: A guide to symptoms, evaluation, and
treatment (2nd edn). Thousand Oaks, CA: Sage.
Herman, J.L. (1997). Trauma and Recovery. New York: Basic Books.
 WORKING WITH PTSD AND COMPLEX TRAUMA 195

Van der Kolk, B. et al. (2006). Traumatic Stress: The effects of overwhelming experience on mind,
body, and society. New York: The Guilford Press.

REFERENCES

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th
edn). Washington, DC: Author.
Boon, S., Steele, K. and Van Der Hart, O. (2011). Coping with Trauma Related Dissociation. New
York: Norton.
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Brewin, C.R., Andrews, B. and Valentine, J.D. (2000). Meta-analysis of risk factors for
posttraumatic stress disorder in trauma exposed adults. Journal of Consulting and Clinical
Psychology, 68, 748–766.
Briere, J. and Scott, C. (2012). Principles of Trauma Therapy: A guide to symptoms, evaluation, and
treatment (2nd edn). Thousand Oaks, CA: Sage.
Cloitre, M., Courtois, C.A., Ford, J.D., Green, B.L., Alexander, P., Briere, J., Herman, J.L.,
Lanius, R., Stolbach, B.C., Spinazzola, J., Van der Kolk, B.A. and Van der Hart, O. (2012).
The ISTSS Expert Consensus Treatment Guidelines for Complex PTSD in Adults. Retrieved
from http://www.istss.org.
Ehlers, A. and Clarke, D.M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour
Research and Therapy, 38, 319–345.
Grey, N., Young, K. and Holmes, E. (2002). Cognitive restructuring within reliving: A
treatment for peritraumatic emotional ‘hotspots’ in posttraumatic stress disorder. Behavioural
and Cognitive Psychotherapy, 30(1), 37–56.
Herman, J. L. (1992). Trauma and Recovery: The aftermath of violence from domestic violence to political
terrorism. New York: The Guilford Press.
Jones, E. and Wessley, S. (2006) Shell Shock to PTSD: Military psychiatry from 1900 to the Gulf
War. Maudsley Series.
Keane, T.M., Brief, D.J., Pratt, E.M. and Miller, M.W. (2007). Assessment of PTSD and its
co morbidity in adults. In M.J. Friedman, T.M. Keane and P.A. Resick (eds), Handbook
of PTSD Science and Practice. New York: The Guilford Press.
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M.B. and Nelson, C.B. (1995). Posttraumatic
Stress Disorder in the National Comorbidity Survey. Archives General Psychiatry, 52(12),
1048–1060.
Kilpatrick, D., Resnick, H.S., Milanak, M.E., Miller, M.W., Keyes, K.M. and Friedman, M.J.
(2013). National Estimates of Exposure to Traumatic Events and PTSD Prevalence Using DSM-
IV and Proposed DSM-5 Criteria [Manuscript submitted for publication].
Lab, D., Santos, I. and Zulueta, F. de (2008) Treating post traumatic stress disorder in the ‘real
world’: Evaluation of a specialist trauma service and adaptations to standard treatment
approaches. Psychiatric Bulletin, 32, 8–12.
McNally, R.J. (2003). Progress and controversy in the study of posttraumatic stress disorder.
Annual Review of Psychology, 54, 229–252.
NICE (National Institute for Clinical Excellence) (2005). The Management of PTSD in Adults
and Children in Primary and Secondary Care (Vol. 26). Wiltshire: Cromwell Press.
 196 MAEVE CROWLEY AND INES SANTOS

Pearlman, L.A. (1999) Self-care for trauma therapists: Ameliorating vicarious traumatisation. In
B.H. Stamm (ed.), Secondary Traumatic Stress: Self care for clinicians, researchers and educators
(2nd edn, pp. 51–64). Baltimore, MD: Sidran Press.
Resick, P.A., and Schnicke, M.K. (1993). Cognitive Processing Therapy for Rape Victims: A treatment
manual. Newbury Park, CA: Sage.
Resick, P., Bovin, M.J., Calloway, A.L., Dick, A.M., King, M.W., Mitchell, K.S. and Wolf,
E.J. (2012). A critical evaluation of the complex PTSD literature: Implications for DSM-
5. Journal of Traumatic Stress, 25, 239–249.
Rothbaum, B.O., Foa, E.B., Riggs, D.S., Murdock, T. and Walsh, W. (1992). A prospective
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examination of post-traumatic stress disorder in rape victims. Journal of Traumatic Stress, 5,

455–475.
Rubin, G.J., Brewin, C.R., Greenberg, N., Hacker Hughes, J., Simpson, J. and Wessely, S.
(2007). Enduring consequences of terrorism: 7-month follow-up survey of reactions to
the bombings in London on 7 July 2005. British Journal of Psychiatry, 190, 350–356.
Shapiro, F. (2001). Eye Movement Desensitisation and Reprocessing: Basic principles, protocols and
procedures (2nd edn). New York: The Guilford Press.
Van der Hart, O., Nijenhuis, E.R.S. and Steele, K. (2006). The Haunted self: Structural dissociation
and the treatment of chronic traumatisation. New York: Norton.
Wilson, N., d’Ardenne, P., Scott, C., Fine, H. and Priebe, S. (2012). Survivors of the London
Bombings with PTSD: A qualitative study of their accounts during CBT treatment.
Traumatology, 18, 75–84.
Wright, D., Ost, J. and French, C. (2006). Recovered and false memories. The Psychologist,
19(6), 352–355.
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4 Working with
people with
disabilities and
physical health
problems
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7KLVSDJHLQWHQWLRQDOO\OHIWEODQN
 12 Working with people
with intellectual
disabilities
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Jan Burns

JAMES’ STORY

My name is James and I am 24 years old. I live with Simon, Colin and Stanley in a
house. It is okay, but the others are noisy and shout sometimes. Care staff help us do
things like shopping and cleaning the house. I go to the day centre and do things on the
computer. I like walking and playing computer games. Mum comes to see me on a
Saturday. I have a brother called Harry. Sometimes I get angry and shout. Mum tells
me off.

SUMMARY

This chapter looks at why, and how, a clinical psychologist might work with a person
with intellectual disabilities. It provides a definition of what intellectual disability is and
how it is assessed. The epidemiology and aetiology of intellectual disabilities will also be
described. The chapter will explain that clinical psychologists do not see people because
they have intellectual disabilities, but as a consequence of the additional challenges faced
by people in this group. Having an intellectual disability may bring additional physical
and life challenges that most people would find difficult to manage. However, having
intellectual disabilities also means that your intellectual capacity is more limited, meaning
that dealing with these issues can be even more difficult, leaving you vulnerable to
experiencing a greater risk of psychological and behavioural problems. Clinical psychologists
are well equipped to help individuals with intellectual disabilities in this situation and
may work directly with them, their carers or with wider organisational care and support
services. The chapter will describe the types of interventions used and their evidence base,
and provide a case example of how such a problem may be assessed, formulated and an
intervention developed. Historically, people with intellectual disabilities have been a group
 200 JAN BURNS

that have been excluded and stigmatised and it has been difficult for them collectively to
challenge this position. Today, the picture is more positive, with people with intellectual
disabilities having more opportunity to voice their concerns and exert their right to access
appropriate services; however, as will be explored at the end of the chapter there remains
a fine balance between the expression of individual choice and protection by others, which
remains one of the most critical issues facing working in this area today.

INTRODUCTION
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This chapter will introduce you to the work of the clinical psychologist working with
people with intellectual disabilities, their carers and the organisations which support
them. Having intellectual disabilities is not a reason alone for being involved with
clinical psychology, but it is often the consequences which accompany these disabilities
which require intervention. It is important to think of it in terms of intellectual
disabilities, not just as an intellectual disability, since individuals will have different
profiles in terms of their cognitive limitations, and while they have strengths in one
area they will have weaknesses in other areas, and as a consequence of this unique
constellation of impairments each person will face different challenges.

Diagnosis of intellectual disability

Intellectual disability (sometimes termed learning disability in the UK) is
defined in DSM-V as an impairment of mental abilities which results in a
reduced ability to manage everyday life, called adaptive functioning. Three
domains or areas of adaptive functioning are described:

1 The conceptual domain which includes skills in language, reading, writing,

memory, maths and reasoning.
2 The social domain refers to empathy, social judgement, interpersonal
communication skills, the ability to make and retain friendships, and similar
capacities.
3 The practical domain includes being able to look after yourself, such as
personal care, money management, getting around and managing your
time.

The intellectual disability must have occurred during the person’s

FOCUS 12.1

developmental period of growth, and diagnosis is based on the severity of

the impact upon adaptive functioning. The disorder is considered chronic and
is often co-morbid with other disorders such as autism. Having an intellectual
disability is not in itself a psychological problem, but the challenges and
stigma attached to the disorder cause significant stress for the individual,
placing them more at risk to psychological problems.
 WORKING WITH INTELLECTUAL DISABILITIES 201

Within this chapter you will learn more about the definition of intellectual
disabilities, what causes them, and other issues which frequently co-occur. You will
also learn about how the clinical psychologist may work with the person with
intellectual disabilities, their carers and the organisations which aim to support them.

WHAT ARE THE TYPES OF PSYCHOLOGICAL DIFFICULTIES THAT

MAY OCCUR IN PEOPLE WITH INTELLECTUAL DISABILITIES?

People with intellectual disabilities can suffer the same sorts of psychological problems
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as anybody else in life. However, the prevalence rates of many psychological problems
tend to be higher for people with intellectual disabilities (Taylor and Knapp, 2013).
This vulnerability results from both the additive (i.e. the accumulation of additional
problems) element of intellectual disabilities and the very nature of the disorder which
means that the individual’s capacity to manage their situation intellectually is
compromised. The additional challenges faced by people with intellectual disabilities
fall into three main areas:

1 Intellectual disability linked disorders. Generally, people with intellectual disabilities

are more likely to have additional physical problems, such as sensory deficits, and
mobility and respiratory problems. Some types of intellectual disabilities are a
consequence of genetic syndromes which also have accompanying additional
disabilities, both physical (e.g. Downs syndrome and hearing loss) and behavioural
(e.g. Prader–Willi syndrome and overeating). Some conditions such as autism,
epilepsy and cerebral palsy also have a greater likelihood of co-occurrence with
intellectual disabilities. The more severe the intellectual disabilities the higher the
likelihood of a range of associated disorders. Having additional physical impair-
ments results in increased vulnerability by impacting upon learning opportunities
and can lead to increased isolation and reduction of stimulation, causing additional
psychological stress.
2 Common psychological problems. People with intellectual disabilities may suffer from
problems such as anxiety and depression, the same as everyone else; however, they
are vulnerable to experiencing this more frequently because of the tough demands
of living in our society with intellectual disabilities. Hence, people with intellectual
disabilities are more vulnerable to all the accepted setting conditions for common
psychological problems such as low income, poor housing, unemployment, poor
health and social isolation.
3 Stigma and prejudice. Having intellectual disabilities within our society is still
stigmatising (i.e. de-valued), which means that people behave in prejudicial and
exclusionary ways. This is especially difficult for people with intellectual disabilities
as they have fewer psychological resources to manage negative attitudes and are
even less able than other disenfranchised groups to fight for their rights. Being in
such a socially devalued position brings additional psychological pressures to an
already vulnerable group.

Hence, clinical psychologists do not tend to see people because they have an intellectual
disability, but more usually as a consequence of them having an intellectual disability
 202 JAN BURNS

Individual (e.g. improve communication skills)

Living situation (e.g. increase meaningful

occupation)

Support structures (e.g. build staff skills)

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FIGURE 12.1 Points of intervention within an ecological framework surrounding an

individual with intellectual disabilities

which has placed them in a more psychologically vulnerable position. It is useful to

consider the problems faced by the individual within an ecological framework, which
may then require the psychologist to work at a number of different levels to minimise
the impact of the impairments caused by the disability. The framework has the
individual within the centre surrounded by support or organisational structures,
offering a variety of ways in which the psychologist may intervene (see Figure 12.1).

EPIDEMIOLOGY

Obtaining accurate statistics on the epidemiology of intellectual disabilities in the UK

is problematic for a number of reasons: first, in terms of identification, second, in terms
of different data collection methods across the UK, and third, through changing
epidemiological profiles related to changing definitions, medical interventions, health
behaviours and demographic profiles. However, a reliable source of information is the
Improving Health and Lives: Intellectual Disabilities Intellectual Disabilities Observatory
(http://www.improvinghealthandlives.org.uk/) which produces regular updates on the
current and changing epidemiology.
It is estimated that in 2012 in England 1,144,000 people had learning disabilities,
of which 236,000 were children and 908,000 adults (aged 18+). Of the adults 199,000
(22%) are known to GPs as people with intellectual disabilities and 404,000 (44%) were
receiving Disability Living Allowance (Emerson et al., 2013). Hence, it is clear from
these statistics that a large number of people are living with either no need of being
identified as having intellectual disabilities, or in contrast are not receiving the required
services.
Of those identified as having intellectual disabilities, the average age of mortality is
24 years (30%) younger than the rest of the population. However, there are important
fluctuations in epidemiology to note resulting from changing medical practices, such
that there is a lower population over the age of 49, and an increasing population of
males under the age of 20. This is because there now tend to be more males born
with intellectual disabilities, particularly with severe intellectual disabilities, where
improvements have been made in survival rates.
 WORKING WITH INTELLECTUAL DISABILITIES 203

AETIOLOGY

A good place to start to understand the aetiology of intellectual disabilities is from the
World Health Organisation’s (WHO) International Classification of Functioning, Disability
and Health (2002), as it provides a useful bio-psychosocial model (see Figure 12.2).

Health condition
(disorder or disease)
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Bodily functions
and structure Activity Participation

Environmental Personal
factors factors

Contextual factors

FIGURE 12.2 International Classification of Functioning, Disability and Health

Source: WHO (2002). © 2002 WHO.

If we start at the top of the model we can consider the biological contributions to
the aetiology of learning disabilities. These include congenital causes, such as genetic
(e.g. Down’s syndrome), acquired, both prenatal (e.g. maternal drug abuse), postnatal
(e.g. birth trauma), social (e.g. malnutrition) and environmental (e.g. toxins). All of
these events may lead to structural and functional negative impacts upon the
neurological system. However, even with careful assessment it must be recognised that
the biological aetiology remains unknown in over 50 per cent of people with
intellectual disabilities (see Smith and Tyler (2009) for further reading on causal factors).
Moving to the middle layer of the diagram we can consider how these biological
factors may impact upon body function and structure. Taking the example of an infant
with Down’s syndrome they are likely to have cognitive deficits, physical differences
such as hypotonia (low muscle tone) and sensory problems such as hearing loss, in
addition to other issues. Considering their ability to be active, and, like any baby, to
explore curiously and play with their environment, without appropriate adjustment
their experience will be more limited. Not being able to hear well, and not having
the expected cognitive reactions and ability to learn, may then impact upon the
interpersonal attachments a person makes and which may further impede their ability
to participate in the activities and relationships around them. Participation is important,
as it brings richer learning opportunities, and reinforces, encourages and motivates
future engagement.
 204 JAN BURNS

Looking at the bottom of the diagram we can see that we must also consider the
environmental and personal factors which will impact upon the outcomes for the
individual with intellectual disabilities. Environmentally, just considering the young
person with Down’s syndrome where their disability is visually recognisable, the
reaction of others to this identity will be very important for the self-esteem and
inclusion of the person. In addition, the existing knowledge about the condition will
have a significant impact upon expectations and importantly what adjustments may
need, or not need, to be made to help the person overcome their disabilities. Personal
factors include the personality of the individual, their own resilience and coping styles,
but also their gender and age, as these will present different challenges during different
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developmental stages.
The WHO model is helpful, as it moves the focus away from the disability to the
more fluid concept of functioning, which is dependent upon the above interrelating
set of factors. Such a model suggests a wider range of possibilities in terms of
intervention. It also raises the issue that contrary to taking a medical, organic approach
to intellectual disabilities, these disabilities could also be conceptualised in terms of a
social construction, i.e. something which only exists in this time and place as a
consequence of how we structure our society (Rapley, 2004). Clearly, we would not
define intellectual disabilities in the same way if we did not have IQ tests with cut-
off points, based on purely statistical concepts, or ways of life which demanded high
levels of literacy. However, likewise some individuals do have such severe impairments
that no matter what their social context was, they would find it impossible to cope.
Holding both positions in mind is helpful in ensuring a holistic approach.

THEORY AND EVIDENCE FOR PSYCHOLOGICAL

INTERVENTION

Psychological interventions with people with intellectual disabilities have a long

history, but mostly within applied behavioural analysis, and less so within the
application of ‘talking therapies’. This was partly due to emphasis being given to the
co-modification of the behaviour of people with intellectual disabilities to ‘fit in’ with
institutional environments, and historical beliefs that their thoughts and feelings were
not accessible. These days a more respectful, integrated approach is taken, particularly
in terms of managing challenging behaviour, and also the full range of therapeutic
modalities are considered as applicable, with appropriate adjustment. The following
sections describe a current behavioural approach to managing behaviours which may
be seen as challenging, followed by a short review of the types of ‘talking therapies’
which have been found to be helpful.

Positive behaviour support

There are times when a person’s behaviour is seen as ‘challenging’, and challenging
behaviour has been defined as follows:

Culturally abnormal behaviour[s] of such an intensity, frequency or duration that

the physical safety of the person or others is likely to be placed in serious jeopardy,
 WORKING WITH INTELLECTUAL DISABILITIES 205

or behaviour which is likely to seriously limit use of, or result in the person being
denied access to, ordinary community facilities.
(Emerson, 2001, p. 3)

Rather than see this as an individual pathology, it is recognised that it is a socially con-
structed, dynamic concept and where the individual’s quality of life and risk managem-
ent are paramount. The most accepted approach to manage challenging behaviour is
positive behaviour support (PBS; Dunlap et al., 2009; Baker and Allen, 2012) which
is based on applied behavior analysis (ABA) principles, but set within a clear framework
of values. As opposed to pure ABA it is also multi-element, non–linear (i.e. recognising
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that multiple antecedents and consequences may act upon a behaviour simultaneously)
and designed to result in a range of outcomes, which are sustainable and achieved
through positive means. PBS has a number of components:

1 Comprehensive functional analysis to try to understand what purpose the

behaviour serves for the individual. Then on the basis of this assessment a number
of strategies are developed.
2 Ecological strategies: trying to ensure that the environment meets the need of the
person as much as possible (e.g. if the individual cannot read, to make sure signage
or communication tools use symbols or pictures which they do recognise).
3 Positive programming: teach the person skills to help them control their
environment (e.g. using headphones).
4 Focused support strategies: designed to manage the context and reduce the need
for reactive strategies (e.g. avoid noisy environment at stressful times).
5 Reactive strategies: designed to gain control of the situation once the behaviour
has occurred, and reduce escalation (e.g. help the individual move to a quieter
place).

PBS is the most commonly recommended approach with challenging behaviour and
there is good evidence for its effectiveness. For example, in a recent review La Vigna
and Willis (2012) concluded that by applying the ethical criterion of ‘least restrictive
intervention’ it is effective, open to all involved in managing such behavior and cost-
effective. It is recognised that the efficacy of the approach is reliant upon those who
need to deliver it which are usually the staff who work directly with the individual
on a day-today basis, so McDonald and McGill (2013) conducted a review of the
effectiveness of teaching staff this approach. They concluded that there was evidence
for a reduction in challenging behaviour, and increases in staff positive attributions and
knowledge; however, they recognised that the evidence was limited and no
improvement in quality of life has been demonstrated.

Talking therapies
More recently talking therapies have been shown to be effective with people with
intellectual disabilities as long as adaptations are made to ensure that the individual can
engage with the model. Willner (2005) reviewed the existing literature on the
effectiveness of cognitive-behavioural therapy (CBT), cognitive therapy and
psychodynamic approaches, and concluded that evidence exists for all three models to
 206 JAN BURNS

be effective with people with mild intellectual disabilities and sometimes effective with
people with more severe intellectual disabilities. However, the review recognised that
research was very limited and in particular lacked randomised controlled designs, and
information on how such models were adapted. Since then a small number of RCTs
have been published with positive results, particularly around using CBT for anger
management (e.g. Willner et al., 2013), and also other studies on helping people with
intellectual disabilities to use CBT (Bruce et al., 2010), and on how simple CBT
elements can be adapted for staff for use with their clients (Dodd et al., 2013).
While Willner (2005) concluded there was some limited evidence for the use of
psychodynamic psychotherapy with this client group, further evidence for its effec-
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tiveness has been slower to follow and the suitability of this model has been increasingly
contested. However, more recently evidence has been growing for its potential
effectiveness, but with a clear acknowledgement that the practices and procedures used
within the application of this modality with this client group requires further
description (Beail and Jackson, 2013).
As the use of ‘talking therapies’ has become more accepted, the breadth of the
therapeutic models being used has widened, following the growing evidence base
within mainstream work. Hence, a recent book, Psychological Therapies for Adults with
Intellectual Disabilities (Taylor et al., 2013), also includes mindfulness and acceptance-
based approaches.

CASE STUDY

Pat is a 46-year-old woman with Down’s syndrome. She has been referred to the
community learning disability team, as she has started to get up and wander at night,
disturbing other residents of the group home and the sleep-over night staff. She
sometimes becomes quite agitated when asked to return to bed, and generally
seems down and weepy. When asked what is wrong she seems unable to identify
anything.

Assessment
Pat was asked by her key worker if she would like to talk to someone about the
problems she has been experiencing. She readily agreed and an appointment was
made for her to see the clinical psychologist on the specialist intellectual disabilities
team. The clinical psychologist explained that she would like to talk to Pat to see if
she could help her, and that it would also help for her to talk to the staff so that she
could get a complete picture. Pat consented to this initial assessment. Pat told the
psychologist that she was aware she was getting up in the night, that it made her
upset and anxious, and that the staff were cross with her, but she did not know why
she did it. On talking to staff it was clear that they were concerned, felt that Pat’s
behaviour had deteriorated generally and wondered if she was starting to show
dementia. The night-time disrupted routines were having a bad effect on the other
residents and one member of staff thought Pat was doing it to get attention, as
 WORKING WITH INTELLECTUAL DISABILITIES 207

Dementia and Down’s syndrome

Down’s syndrome (DS) is the most common genetic cause of learning
disabilities. Due to better medical intervention in early life, people with DS are
now living longer and the higher prevalence rate of dementia for people with
Down’s syndrome at an earlier expected age has been recognised. Research
suggests that co-morbidity is between 10 and 25 per cent in the 40- to 49-
year-old group, 20 and 50 per cent in the 50- to 59-year-old group and
between 30 and 75 per cent in those aged 60 years or older. There seems to
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be no relationship between level of learning disability and risk of dementia,

but pre-existing cognitive function is related to rate of decline. Behavioural
change tends to indicate onset more frequently than functional memory
decline. The most common form of dementia co-morbid with DS is of the
Alzheimer’s type. The link is related to the shared function of the protein
FOCUS 12.2

Amyloid. Amyloid forms the neural plaques found in Alzheimer’s disease and
the gene coding for this protein is located on chromosome 21. The majority
of people who have DS have the ‘trisomy 21’ form which means they have
an extra copy of this chromosome, disrupting normal Amyloid production.
However, not all people with DS develop dementia in later life and the reason
for this is unclear.

sometimes she was given a hot chocolate and chat before returning to bed. When
asked if anything had changed recently, staff mentioned that Pat’s auntie who she
was close to had died about six months previously and they had had some work
done to the house, which meant that the upstairs bathroom had been out of
commission for a couple of weeks, so residents had had to use the downstairs
bathroom, but it was all fine now.
It was agreed, given Pat’s age and the existence of no previous dementia
screening, that she should undergo some psychometric tests, and meanwhile more
information would be gathered about Pat’s nocturnal behaviour and generally how
she was feeling. With Pat’s consent ABC charts were completed by the night staff
over a three-week period; these logged ‘Antecedents’ (i.e. anything staff noticed
before Pat got up in the night), the ‘Behaviour’ (i.e. what she did and what staff did)
and ‘Consequences’ (i.e. what happened afterwards). The clinical psychologist also
agreed with Pat to meet her for six sessions to discuss how she was feeling and to
try to understand what led to the nocturnal wandering.

Formulation
It is important in a complex case such as this that a very careful and thorough
assessment is made which is based on an initial formulation. As the work progresses
 208 JAN BURNS

it is likely that additional information will come to light which enriches and confirms
or rejects ideas present in the initial formulation. The following formulation is an initial
formulation which leads to an action plan to gather more information, which will in
turn lead to the consolidation of the most appropriate formulation of the problem and
continuing action plan.
It seemed clear that something had changed to give rise to these alterations in
behaviour which had not been reported before. There may be a number of reasons
for this change. Given Pat’s age and Down’s syndrome she has a 25 to 50 per cent
higher chance than those without Down’s syndrome of developing dementia which
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can lead to confusion, anxiety and behavioural change. Down’s syndrome and
dementia were potential ‘predisposing’ factors (making Pat more at risk of the
current problems), to be investigated further. Pat had also recently experienced the
death of someone close to her, and with no other close family this loss was
significant. The grieving process is individual but it is likely that Pat was still mourning
this loss. At a practical level there had been some work done on the house which
may have disrupted her usual routines, and on top of these other factors she was
finding it hard to re-establish a routine. These could be termed ‘precipitating’ factors,
as bereavement is a known cause of psychological distress, and having routines
disrupted can be particularly upsetting for people with intellectual disabilities, and
Pat’s behaviour changed quite soon after these events.
Pat was also starting to feel generally quite anxious as she felt staff may be
feeling cross with her, which again may disrupt her sleep. This could be seen as a
‘perpetuating’ factor because it maintains the behaviour, possibly beyond the
influence of the initial precipitating events. As Pat becomes more aware of the staff’s
negative feelings, she becomes more anxious, which in turn disrupts her sleep, and
the events continue in a cyclical fashion. Any combination of these factors could have
been contributing to this behaviour, so it was important to find out more information
before intervening.

Action plan
Comprehensive assessment
• A dementia screening assessment was carried out using the neuropsychological
assessment of dementia in adults with intellectual disabilities (NAintellectual
disabilities) (Crayton et al., 1998). In addition, to establish a behavioural baseline
Pat’s adaptive functioning was assessed using the Adaptive Behaviour
Assessment System-II (ABAS-II) (Harrison and Oakland, 2003).
• The Glasgow Anxiety Scale for people with an intellectual disability (GAS-
intellectual disabilities) was used to assess level of anxiety (Mindham and Espie,
2003). Pat scored 13, which just hit the cut-off of 13 to 15 to be seen as clinically
significant.
• The clinical psychologist met with Pat to explore with her in greater depth the
anxiety she was experiencing. They also talked in detail about Pat’s bedtime
 WORKING WITH INTELLECTUAL DISABILITIES 209

routines. She had felt disrupted by the work on the house, now sometimes
forgetting to get a drink of water and going to the toilet before bed. She was also
anxious about turning the lights on when she got up in case she woke the night
staff, who slept with the door open, but then she ended up going into the wrong
room or having to turn the light on, which made her feel cross with herself and
embarrassed.
• Ten ABC charts were completed over a three-week time period, showing that Pat
did not get up every night, and there was no particular pattern in terms of which
days, but that it did tend to happen at around 2 a.m. She then stayed up for
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variable amounts of time depending on what approach staff took. Some tried to
send her back to bed, which tended to make her agitated; others sat up with her
for a while and sometimes made a drink. There was only one occasion when she
got up more than once.

Reformulation
According to the screening, Pat did not have dementia, but, given this
predisposing factor, having a baseline screening follows national guidance. The
precipitating factor of bereavement did seem significant, and hence it was
appropriate to intervene to resolve some issues and reduce distress about this
event. The assessment also illuminated another perpetuating factor: Pat was
keeping the light off to reduce disturbance but by doing so she was causing more
disturbance and adding to her anxiety levels. The assessment also confirmed that
the disruption to routines through building work had perpetuated the situation;
hence it was clear that a more standard routine needed to be re-established and
agreed with Pat and the staff.

Intervention
• A meeting was held with the staff team to discuss the results of the assessment
and action plan. After consulting Pat a procedure was agreed about what should
happen if Pat got up, which consisted of two main elements: checking if she
wanted to go to the toilet, and going with her to get a drink of water (not a hot
drink), then going with her back to her room and settling her in bed. Pat was also
to be reassured by staff that they were not cross about her waking. Time was also
spent carefully explaining this to Pat’s key worker so that she could ensure that all
the night staff who could not make the meeting were well informed.
• Pat formed a good rapport with the clinical psychologist and they spent time
discussing her deceased auntie, what grief feels like and how things start to feel
better. They used a downloadable booklet about grief specifically for people with
intellectual disabilities, developed by the NHS North Tyne’s Liverpool Care
Pathway group (NHS North East, 2012).
• Pat agreed that she still felt very sad about her auntie’s death, but felt she could
not say this to the staff as she thought they might think ‘she was going on’ and
 210 JAN BURNS

‘should be over it now’, because they never mentioned her auntie now. Pat agreed
that the clinical psychologist could let the rest of the staff team know this and
Pat’s key worker suggested that together they could make a photo album
featuring her auntie.
• Night-lights had been installed in the corridor to the bathroom, which made Pat
feel more confident.

Outcome
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• The dementia screening did not show any dementia, but it was agreed that Pat
should be assessed on an annual basis.
• Pat had previously scored 13 on the GAS-intellectual disabilities, but when tested
eight weeks later this had reduced to 8, indicating a return to normal levels of
anxiety.
• The staff team stuck to the agreed procedure and after another three-week
period of monitoring with ABC charts there had been only one incident.
• Staff members reported feeling more confident and relieved. They were
especially pleased that they raised the topic of dementia and that they had
followed the guidelines (Royal College of Psychiatry and Division of Clinical
Psychology, 2009), in that they were right to be concerned given Pat’s age,
Down’s syndrome and change in behaviour (reactive monitoring), and that
Pat was now registered for annual reviews (prospective monitoring). Staff had
found the ABC charts helpful and reported that they would use them again.
They also realised that their anxiety had been noticed by Pat and misinterpreted
by her as them being angry with her, and hence how important it was to check
with Pat what she was thinking.

Team working/indirect work

It was very important to work with the staff team in this case as these were the
people who knew Pat the best and spent long periods of time with her. There was
clearly a communication difficulty in that the staff were genuinely concerned, but
Pat misinterpreted this which made her feel more anxious, exacerbating the
situation. It is not uncommon for seemingly simple and predictable feelings and
interactional dynamics to become confused, so asking both the staff team and the
client what they might feel and how they might behave in the other’s situation is a
good way of testing out and challenging these beliefs.
Setting systems in place that are sustainable is very important, as the clinical
psychologist is only likely to be involved for a short period of time and the bulk of the
work will be carried out and continued by the staff team. Hence, their active
engagement is vital. In addition, each clinical intervention is an opportunity to provide
the staff team with more understanding, tools and strategies to help them in their
work and to offer an improving service to their clients. In this case seeking Pat’s
 WORKING WITH INTELLECTUAL DISABILITIES 211

approval to talk to the staff team about how she was feeling was vital. It also
provided an opportunity to find out how they were feeling and to be able to identify
some misunderstandings. It was also important to identify with both the staff and Pat
the outcomes they desired. In this situation they were shared outcomes, meaning
that we could find strategies to work together for an agreed outcome. When
objectives are not shared between the client and staff or even within the same staff
team this must be identified and worked upon. It was also important to contextualise
the staff’s ‘hunch’ that they ‘needed to check for dementia’. Discussing the
‘Dementia and People with Learning Disabilities’ guidelines with the staff made them
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feel confident in their decision making, and gave them a resource to draw upon
should they have further concerns. Likewise, the ABC chart was a resource they
found helpful and could see themselves using again, which may increase their own
capacity to problem solve similar situations.
In this case the work of the clinical psychologist was quite contained to Pat and
the direct team who worked with her. However, it is not uncommon to involve other
members of the multi-disciplinary team such as the speech and language therapist
for communication issues, or the team nurse to help manage physical issues. In
addition, wider issues may be identified where staff training by the psychologist may
be of benefit, or there may be problems with how the team is working where again
the clinical psychologist could help.

CRITICAL ISSUES

As the rights of people with intellectual disabilities have been given more attention,
the centrality of their voice and choices has also been given more authority. However,
with this comes difficult and complex choice making around a vulnerable person’s right
to be protected and their right to act in the way they choose. Many of the critical
issues within the field of psychology and intellectual disabilities currently centre on
this dilemma. One particularly contested area of work is around the expression of
sexuality, where issues of right to choose, consent, parenthood, protection of self and
others, and public prejudice have all had to be addressed.
Historically the sexuality of people with intellectual disabilities has been either
denied or tightly controlled. Today it is acknowledged that all people with intellectual
disabilities have the same rights to a sex life as everybody else, while acknowledging
that this must be within consensual understanding (McCarthy and Thompson, 2010).
This may be difficult in two particular circumstances, when the individual(s) concerned
lack understanding to give consent, and/or there is such a power imbalance that
coercion may be involved. With heterosexual sex comes the possibility of pregnancy,
so not only must individuals have the capacity to understand the sexual act, they must
also understand that this may lead to conception, and to make the choice to accept
this possibility or be able to take precautions. For clinical psychologists these dilemmas
have brought not only many invitations to become involved in trying to establish
‘capacity for consent’, but also to provide assistance in assessment and intervention to
help people live sexually fulfilled lives.
 212 JAN BURNS

Concerning sexual behaviour, this may involve straightforward sex education, to

helping staff work through complex issues such as a young man with intellectual
disabilities asking a member of staff to show them how to put on a condom. Like the
mainstream world some people with intellectual disabilities wish to engage in less
normative sexual practices and, for staff concerned about the expression of sexuality
anyway, managing a client who wants to cross-dress or has a shoe fetish poses
additional challenges. Commonly in such complex, ethically challenging cases clinical
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psychologists are invited in to assist in helping staff both establish capacity for consent
and support staff through the array of complex decisions and actions which may lie
before them.
At a more serious edge of transgression lies sexual offending and there has been a
rapid growth in forensic psychology with this client group. With rights comes
responsibilities, and if people with intellectual disabilities are found to have capacity
and make wrong decisions then they have become increasingly involved in the
judicial system. Likewise it may not be recognised that offenders have intellectual
disabilities and we have seen recognition of a large prison population with unmet needs
in this area.

JAMES’ STORY: CONCLUSION

I met Amy who is a psychologist. She helped me and told me what to do if I feel angry.
We had a house meeting and Amy came too. We agreed some rules about making
noise and Amy drew pictures and put them on the wall. If Colin is noisy I point to the
picture and he shuts up.
In the morning I go with Jim now and deliver newspapers. It was hard at first but I
like it now. People say ‘hello James’ and I give them their paper.

KEY CONCEPTS AND TERMS

• Learning disabilities • Challenging • Capacity

• Intellectual disabilities behaviour • Stigma
• Cognitive functioning • Down’s syndrome • Working with staff
• Autism • Positive behavioural • Sexuality
• Adaptive behaviour support • Dementia
• Developmental • Applied behaviour
period analysis
 WORKING WITH INTELLECTUAL DISABILITIES 213

LEARNING OUTCOMES

When you have completed this chapter you should be able to:

1 Know what intellectual disabilities are, what might be some of the causes, and
other issues which co-occur.
2 Have an understanding of the sorts of challenges people with intellectual
disabilities may face both dealing with their own impairments, but also dealing
with the views of society.
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3 Be able to position the experience of people with intellectual disabilities within

wider psychological theories.
4 Have an understanding of the key psychological approaches in this area, how
other treatment approaches might be adapted, and the evidence base for this.
5 Through a case example understand how assessment, formulation, intervention
and evaluation are used.
6 Be able to understand how different approaches, at different levels from the
individual to the support network, may be integrated to be effective and
sustainable.

SAMPLE ESSAY TITLES

• Is ‘learning disability’ a social construction?

• What is ‘challenging behaviour’ and how is it best managed?
• How has the acceptance of the sexuality of people with intellectual disabilities
changed over the years?
• Do we understand the link between Down’s syndrome and dementia?

FURTHER READING

Emerson, E., Hatton, C., Dickson, K., Gone, R. and Caine, A. (eds) (2012). Clinical Psychology
and People with Intellectual Disabilities. New York: John Wiley & Sons.
Webb, J. (2013). A Guide to Psychological Understanding of People with Learning Disabilities: Eight
domains and three stories. Abingdon, Oxon: Routledge.

REFERENCES

Baker, P. and Allen, D. (2012). Use of positive behaviour support to tackle challenging
behaviour. Learning Disability Practice, 15(1), 18–20.
British Psychological Society, Royal College of Psychiatrists, and Royal College of Speech and
Language Therapists (2007). Challenging Behaviour: A Unified Approach. Leicester: DCP,
British Psychological Society.
 214 JAN BURNS

Brown, M., Duff, H., Karatzias, T. and Horsburgh, D. (2011). A review of the literature relating
to psychological interventions and people with intellectual disabilities: Issues for research,
policy, education and clinical practice. Journal of Intellectual Disabilities, 15(1), 31–45.
Bruce, M., Collins, S., Langdon, P., Powlitch, S. and Reynolds, S. (2010). Does training
improve understanding of core concepts in cognitive behaviour therapy by people with
intellectual disabilities? A randomized experiment. British Journal of Clinical Psychology, 49(1),
1–13.
Crayton, L., Oliver, O., Holland, A., Bradbury, J. and Hall, S. (1998). The neuropsychological
assessment of age-related cognitive deficits in adults with Down’s syndrome. Journal of
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Applied Research in Intellectual Disabilities, 11, 255–272.

Dodd, K., Austin, K., Baxter, L., Jennison, J., Kenny, M., Lippold, T. and Wilcox, E. (2013).
Effectiveness of brief training in cognitive behaviour therapy techniques for staff working
with people with intellectual disabilities. Advances in Mental Health and Intellectual Disabilities,
7(5), 8–8.
Dunlap, G., Sailor, W., Horner, R. and Sugai, G. (2009). Overview and history of positive
behavior support. In W. Sailor, G. Dunlap, G. Sugai and R. Horner (eds), Handbook of
Positive Behavior Support. New York: Springer.
Emerson, 1995, cited in Emerson, E. (2001, 2nd edn). Challenging Behaviour: Analysis and
intervention in people with learning disabilities. Cambridge: Cambridge University Press.
Emerson, E., Hatton, C., Robertson, J. Baines, S., Christie, A. and Glover, G. (2013). People
with Intellectual Disabilities in England in 2012. Improving Health and Lives: Intellectual
Disabilities Intellectual Disabilities Observatory.
Harrison, P.L. and Oakland, T. (2003). Adaptive Behaviour Assessment System (ABAS-II) (2nd
edn). New York: The Psychological Corporation.
La Vigna, G. and Willis, T. (2012). The efficacy of positive behavioural support with the most
challenging behaviour: The evidence and its implications. Journal of Intellectual and
Developmental Disability, 37, 185–195.
MacDonald, A. and McGill, P. (2013). Outcomes of staff training in positive behaviour support:
A systematic review. Journal of Developmental and Physical Disabilities, 25(1), 17–33.
McCarthy, M. and Thompson, D. (eds) (2010). Sexuality and Learning Disabilities: A handbook.
Brighton: Pavilion.
Mindham, J. and Espie, C.A. (2003). Glasgow Anxiety Scale for people with an intellectual
disability (GAS-ID): Development and psychometric properties of a new measure for use
with people with mild intellectual disability. Journal of Intellectual Disability Research, 47(1),
22–30.
NHS North of Tyne (2012). Grieving – Easy Read – Supplementary Booklet. NHS North East.
Available online at http://www.cnne.org.uk/end-of-life-care—-the-clinical-network/car
eatendoflife (accessed 16 January 2014).
Rapley, M. (2004). The Social Construction of Intellectual Disability. Cambridge: Cambridge
University Press.
Royal College of Psychiatrists and Division of Clinical Psychology: Faculty for Learning
Disabilities (2009). Dementia and People with Intellectual Disabilities. Intellectual Disabilities
Guidance on the assessment, diagnosis, treatment and support of people with intellectual disabilities
who develop dementia. Leicester: British Psychological Society.
 WORKING WITH INTELLECTUAL DISABILITIES 215

Smith, D. and Tyler, N. (2009). Introduction to Special Education: Making a difference (7th edn).
New Jersey: Pearson.
Taylor, J. and Knapp, M. (2013). Mental health and emotional problems in people with
intellectual disabilities. In J. Taylor, W. Lindsay, R. Hastings and C. Hatton (eds),
Psychological Therapies for Adults with Intellectual Disabilities. New York: Wiley.
Taylor, J., Lindsay, W., Hastings, R. and Hatton, C. (eds) (2013). Psychological Therapies for Adults
with Intellectual Disabilities. New York: Wiley.
Willner, P. (2005). The effectiveness of psychotherapeutic interventions for people with
learning disabilities: A critical overview. Journal of Intellectual Disability Research, 49, 73–85.
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Willner, P., Rose, J., Jahoda, A., Kroese, B.S., Felce, D., Cohen, D. and Hood, K. (2013).
Group-based cognitive-behavioural anger management for people with mild to moderate
intellectual disabilities: Cluster randomised controlled trial. The British Journal of Psychiatry.
doi:10.1192/bjp.bp.112.124529.
World Health Organisation (2002). Towards a Common Language for Functioning, Disability and
Health: ICF – the International Classification of Functioning, Disability and Health. Geneva:
WHO.
 13 Working with people
with physical health
problems
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Angela Busuttil, Alesia Moulton-Perkins

and Monika Tuite

LIZZIE’S STORY

My name is Lizzie. I am a 57-year-old lady who was diagnosed with Systemic Lupus
(SLE) and Sjögren’s syndrome in the spring of 2010. Both of these conditions are
incurable auto-immune diseases and have had an enormous impact upon my physical
and mental well-being.
I left hospital with a diagnosis, detailed literature and a cocktail of drugs, and spent
several months in a haze of panic and bewilderment feeling defeated, lonely and
scared.
The initial shock and subsequent long-term implications have been unforgiving and
changed my life completely.
The symptoms of my illness are constant: immense joint pain and exhaustion,
migraine, allergies to food and medication, sensitivity to sunlight, hair loss, muscle
spasms, skin rashes, anxiety and depression. I have been left unable to eat or swallow
normal everyday foods and have increasing problems with my eyesight. I was
overwhelmed by feelings of hopelessness, sadness and isolation. I felt my illness had
stolen everything from me, including my identity, my self-confidence, self-esteem,
social life and personal appearance.
I became reclusive and self-loathing, lost and frustrated that the ‘old me’ had gone
forever. I mourned my old life. I considered suicide but was prevented by the love of my
son, with whom I live. I was referred to the pain management service in 2011 for an
assessment and then began one-to-one narrative therapy with a psychologist.
 WORKING WITH PHYSICAL HEALTH PROBLEMS 217

SUMMARY

The part can never be well unless the whole is well.

(Plato 427 BC, Charmides)

Holistic care is not a new concept. Integrating physical and mental health care both
conceptually and in service delivery is a challenge with which psychologists working in
physical health engage every day. The breadth of this work is significant. The
international classification of diseases (ICD 10; WHO, 1992) covers 16 diagnostic
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categories of which mental disorders is but one. Psychologists working in health potentially
work across all 16. Despite presenting considerable challenges, our increasing
understanding of the relationship between physical and psychological health means that
psychologists are now producing significant health benefits in clinical conditions that were
traditionally the domain of physical health experts.
This chapter will describe what clinical health psychology is and what a clinical health
psychologist does. It will describe some of the psychological issues that contribute to, are
part of, or which follow as a consequence of certain types of physical health problems. It
will introduce some of the theoretical models used by clinical psychologists working in
physical health settings. It will also give examples of the types of clinical issues that present
and describe how a clinical psychologist might work with them in practice using a case
example.

INTRODUCTION

Clinical health psychology involves applying our scientific understanding of psychology

to the types of psychological difficulties which contribute to physical health problems,
which maintain or exacerbate physical health problems, and which result from physical
health problems. These psychological factors include health beliefs and behaviours,
coping mechanisms and resilience factors, as well as issues relating to mental health
such as anxiety, depression and trauma.
Clinical health psychology services are usually provided by clinical psychologists who
work in physical health settings, although health and other applied psychologists also
undertake some aspects of this work. They usually work with multi-disciplinary teams
and deliver psychological interventions to individuals and families, as well as to health
care organisations as a whole. They use a bio-psychosocial perspective (integrating
medical, psychological and social components of a person’s difficulties) and in delivering
services across a wide range of physical conditions there is considerable variety in work-
ing practice and settings. They may apply their skills on hospital wards, in outpatient
teams or in community services.
Areas of service delivery include supporting people with long-term conditions such
as diabetes, supporting health-related behaviour change, conducting pre-surgical
assessment (e.g. for organ transplantation), and working with people facing end-of-
life issues.
 218 ANGELA BUSUTTIL ET AL.

THE RELATIONSHIP BETWEEN PSYCHOLOGICAL DIFFICULTIES

AND PHYSICAL HEALTH PROBLEMS

Psychological distress can result from many types of physical difficulties, although the
level of distress is not always directly related to the severity of the illness. There are a
number of factors that, when taken together, will mediate the nature of the relationship
between physical health and emotional distress. It is important for a clinical health
psychologist to be aware of these mediating factors as they can often suggest how a
psychologist may best intervene to help someone in distress. They need to be thought
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about and understood, and this is a key part of any initial assessment and formulation
process. These factors include the following.

The nature of the illness

The illness
The nature of the illness and its prognosis will directly impact upon the physical and
psychological challenges presented. Is the illness acute or chronic, or made up of single
or multiple conditions? Is it stable or are there periods of exacerbation and remission?
Was the patient born with the condition or is it acquired? If genetic, might it be
transmitted? How will illness and treatment impact upon quality of life, now and in
the future?
With frequently little time to deal with diagnosis before having to consider
potentially distressing treatment (Galloway et al., 1997), rapidly unfolding events may
lead to feelings of powerlessness with threats to physical and emotional identity, work,
role and financial security. With chronic or terminal illness, people often need to
review self-concepts, roles and relationships, and grieve for the loss of their anticipated
future. All of these variables will impact significantly upon how any one physical
problem is experienced and they will need to be assessed and their impact determined
in work with any one patient.

Cognitive problems
Cognitive problems (difficulties in doing certain mental tasks) may be associated with
certain conditions (e.g. hypertension) or result from the side effects of medication.
Coping with cognitive problems can be difficult and leave people more vulnerable to
feeling anxious or depressed.

Transdiagnostic difficulties
Sleep problems, weight management, fatigue, sexual concerns and pain can accom-
pany many different types of physical health problem. Each of these difficulties, which
occur alongside the physical problem itself, can add a significant additional burden and
leave someone more vulnerable to increased levels of distress which can then in turn
make these problems worse. The impacts of sleep deprivation and sexual dysfunction
are explored further in Focus 13.1 and 13.2.
 WORKING WITH PHYSICAL HEALTH PROBLEMS 219

The importance of sleep

Sleep is essential for well-being. Persistent poor sleep affects cognitive skills
such as attention and memory; it affects mood and energy levels, and
impacts upon task performance and relationships. Poor sleep increases the
risk of conditions such as high blood pressure, stroke, diabetes and
depression, and can negatively affect functioning of the immune system
(Robotham et al., 2011).
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Sleep problems such as onset insomnia and maintenance insomnia are

more common in those with physical health problems and there are many
reasons why insomnia is more prevalent. Symptoms such as pain and
breathing difficulties, frequency of urination or difficulties associated with
taking medication can impact negatively upon sleep.
FOCUS 13.1

Organic disease is not always sufficient to account for sleep problems in

this group. Psychosocial factors can also play a part. CBT is recommended as
a first-line treatment for insomnia (Wilson et al., 2010). In chronic illness it can
do more than improve levels of tiredness; it can lead to improvements in the
underlying disorder, in the ability of the individual to function and in emotional
well-being.

Talking about sex

Sex and sexuality impact upon quality of life. Sex can increase intimacy in
central relationships, affirm self-esteem and be a valuable source of comfort.
For people with chronic illness, sexuality can take on added emphasis; being
sexual potentially helps people feel ‘normal’, and arguably this is particularly
important for those with physical health problems whose lives may have
significantly changed.
Physical health issues may impact upon sexual functioning. This may be
for physical reasons, as hormonal, neurological, vascular and pulmonary
function impact upon sexual function. Medication, fatigue and pain can also
have an impact. Psychological factors such as self-confidence, beliefs about
appearance and mood will also affect the expression of sexuality.
Illness may also impact upon sex through changes which occur in the
nature of relationships. Couples may struggle to manage shifts from
FOCUS 13.2

caregiver–patient role to that of lovers. Pre-existing relationship difficulties

may be exacerbated by the additional demands imposed in managing illness.
Health care professionals are not always knowledgeable about the impact
of illness upon sex and may be uncomfortable raising sex as an issue.
McInnes (2003) writes that sexual problems are under-recognised, and under-
treated in physical illness as a result.
 220 ANGELA BUSUTTIL ET AL.

Personal factors
The following personal characteristics or attributes will also impact upon a person’s
capacity to live with or adjust to their condition.
Health/illness beliefs
Adopting healthy behaviours and desisting from unhealthy ones involves making the
decision to change, implement change and maintain change. Likelihood of change is
influenced by: (1) belief that one is at personal risk; (2) outcome expectancy that
behavioural change will decrease risk; (3) the belief that one can change and maintain
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change (Bandura, 1994). The nature of these health beliefs is very important in
determining a person’s psychological response to a particular physical condition and
to their willingness to adopt the treatment regime associated with it.
Coping style
The relationship between physical health problems and psychological distress is also
influenced by a person’s coping style (Miller et al., 1996). Coping is a dynamic process
influenced by individual and environmental factors. ‘Acute’ illness, where disruption
to one’s life may be temporary, calls upon different coping responses to that in ‘chronic
illness’ where the goal is to maintain quality of life, manage symptoms and reduce
disability. Coping strategies interrelate and may be helpful or unhelpful depending upon
the context.
Adjustment
Moos and Holahan (2007) describe the following adaptive tasks in illness and disability:

• managing symptoms and treatment;

• forming relationships with health care professionals;
• managing emotions;
• maintaining self-image;
• relating to family and friends;
• dealing with an uncertain future.

While most people successfully adjust, the process of adjustment is fluid and changing,
accompanying changes in either the physical condition or a person’s life circumstances.
Self-blame can feature if lifestyle choices contributed to the condition. An inability to
undertake family or work roles expected by self or society may result in shame and
guilt, as this can make adjustment more difficult. Some people may struggle to adapt
to changes in their appearance. Positive developments also occur; over a quarter of
patients with diabetes reported positive outcomes in at least one area of their lives
(Tarkun et al., 2013).
Lifespan issues
The point we are at in our lives can affect our psychological response to illness or
disability. Some types of disability may be easier to adjust to later in life than earlier
in life, as there can be a cultural expectation of having to manage more complex
physical health concerns in later life which can make disability less unexpected. A
 WORKING WITH PHYSICAL HEALTH PROBLEMS 221

person with persistent pain may have adapted well but may need to make new
adaptations when they have children and find that they cannot undertake expected
parental roles. Thus adjustment, particularly to a long-term condition, remains a fluid
ongoing process.
Existential issues
Illness confronts patients with the deepest human concerns: death is inevitable, we are
essentially alone, we are looking for meaning and, while we have freedom, with that
comes responsibility for the decisions we make, including those relating to the
consequences of accepting or rejecting treatment. People may differ widely in their
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capacity to process and make sense of these existential issues. People who can create
a sense of meaning from their difficulties tend to adjust better than those who cannot.

Societal factors
The type of society you live in, including cultural beliefs about illness and the types
of support available, can also have a significant impact upon how someone copes with
their physical illness. These societal factors include the following.
Culture, gender and religious factors
These all affect illness experience. A young male unable to work because of a health
condition may experience more stigma than a young female, as it is still more
acceptable for a woman to have other roles in society. Culture and religion may affect
how an illness is perceived, with some viewing some forms of illness as a punishment
and others viewing it as an opportunity for further spiritual development. This
obviously has a major impact upon how someone comes to make sense of, and cope
with, their illness as well as the amount of support they are likely to get from society,
family and friends.
Stigma
Stigma is associated with some types of physical health problems, and the shame that
can result from this can further impact upon the distress caused by the condition. For
example, lung cancer, obesity and AIDS are all often seen as being self-induced, and
people can feel very ashamed about their condition. Stigma may also result if the
aetiology of a condition is unclear (Nelson et al., 2012). Concepts such as ‘somatisation’
and ‘functional disorder’ can leave patients feeling that health care professionals doubt
whether illness and suffering is ‘real’, adding to illness burden.

EPIDEMIOLOGY OF PSYCHOLOGICAL DISTRESS IN PHYSICAL

HEALTH PROBLEMS

Long-term physical health conditions affect approximately one-third of the population

(Naylor et al., 2012) and are often associated with mental health concerns. For
example, depression is three times more common in people with conditions like
diabetes and heart disease (NICE, 2009) than in the general population. Co-morbid
depression also increases risk of mortality and morbidity in people with long-term
 222 ANGELA BUSUTTIL ET AL.

conditions. For example, a person with chronic obstructive pulmonary disease (COPD)
and depression is three times more likely to die than someone with COPD alone. This
may be partly explained by depression affecting patient treatment adherence and self-
care. Some resort to suicide. Druss and Pincus (2000) found that a general medical
condition increased the risk of someone making a suicide attempt by 1.6 times and
more than one medical illness increased risk 2.4 times. With cancer and asthma, risk
was fourfold. Yet physical health clinicians may not always screen for mental health
problems. Some patients merely report physical symptoms, perhaps because of shame
or considering mood irrelevant. Failing to meet mental health needs associated with
physical health is expensive, with estimated increases in health care costs of 45 per cent
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for each person (Naylor et al., 2012).

Mental health problems including psychological trauma also increase risk of physical
health problems (Kendall-Tackett 2009). People with schizophrenia or bipolar disorder
die between 16 and 25 years sooner on average than the general population. We still
don’t fully understand the reasons for this, although modifiable risk factors like
smoking or obesity that are associated with patients’ attempts to manage distress, and
the accompanying side effects of medication, both play a part.

AETIOLOGY OF PSYCHOLOGICAL DISTRESS IN PHYSICAL

HEALTH PROBLEMS

Trying to understand the origins of distress among people with physical health diffi-
culties is a little like trying to solve the proverbial ‘chicken and egg’ paradox. Being
physically ill can make you psychologically distressed, but being distressed can also make
you physically ill.
Most people would understand why someone might become low or anxious when
a long-term physical health problem disrupts relationships or work. It is less obvious
why others survive these challenges without serious detriment to their mental health.
Clinical health psychologists recognise that psychological factors such as health beliefs
and behaviours affect health problems. Lazarus and Folkman’s (1984) cognitive stress-
coping model suggests that the way in which we appraise adverse events like illness
affects how effectively we cope with them. For example, someone who approaches a
diagnosis of cancer with an optimistic ‘fighting spirit’, rather than hopelessness, is more
likely to make positive behavioural health choices such as quitting smoking and
following treatment recommendations.
Bio-psychosocial theories have gone further than this and seek to explain the two-
way nature of physical and mental health. Engel (1977) was one of the first to raise
the possibility that our social environment, psychological make-up and biology interact
to determine health. In the field of persistent pain, Melzack and Wall’s (1967) gate-
control theory provided a model to explain how people with similar objective medical
findings reported widely differing pain levels. Their model suggested that psychological
factors mediate a patient’s subjective experience of pain by opening or closing a
metaphorical ‘gate’ in the spinal cord. Positive nerve impulses from the brain, including
relaxation, narrow this gate, thus dampening pain signals travelling to the brain where
they are processed and perceived as pain. Distress effectively ‘opens’ the gate, enhancing
pain processing.
 WORKING WITH PHYSICAL HEALTH PROBLEMS 223

Recent psychoneuro-immunology (PNI) studies suggest that stress and psychological

factors influence a range of disease processes, from cancer to the common cold. Stress
affects the hypothalamic–pituitary–adrenal axis (HPA) and sympathetic nervous system,
impacting upon the functioning of the immune system. Kiecolt-Glaser et al. (2002)
cited studies where acute stressors such as taking exams, or chronic stressors like caring
for someone with Alzheimer’s, delay immune processes like wound healing. Psycho-
social factors modify these biological processes. For instance, people with fewer social
ties developed more colds, and pessimistic HIV-infected men experienced faster
immune decline. Non-infectious diseases are affected also. For example, depression
raises heart disease risk by 50 to 100 per cent (Benton et al., 2007). Conversely, during
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illness the immune system releases certain chemicals which act on the brain and cause
the ‘sickness response’ mimicking depression symptoms such as tiredness, poor appetite
and withdrawal behaviours. Inflammatory immune responses may contribute to
explaining the increased prevalence of depression in physically ill people (Dantzer
et al., 2008).

PSYCHOLOGICAL INTERVENTIONS USED IN PHYSICAL

HEALTH CARE SETTINGS

Many psychological approaches are used and adapted in work with people with physical
health problems. The assessment will always seek to identify the impact of the various
factors already described upon a person’s psychological response to their condition.
This leads to a theory-based formulation of a person’s emotional difficulties and the
interaction between their emotional and physical difficulties. The formulation leads
to a treatment plan and the choice of treatment approach. The most commonly used
treatment approaches include the following.

Cognitive-behavioural therapy approaches

The basic underpinnings of a CBT approach have been described in previous chapters
(see especially Chapter 2). It has been shown to be helpful in managing depression in
chronic health problems (NICE, 2009) as well as in the treatment of anxiety,
depression, and trauma more generally (NICE, 2008).
In people with physical health problems in particular, CBT can help in managing
distress, enabling people to maintain a positive but realistic attitude towards their illness.
Enhancing communication skills can be helpful in both relationships with family and
health care professionals, and also in dealing with stigma. Pacing is a commonly used
behavioural intervention where patients manage pain and fatigue levels by breaking
up their activities (White, 2001). CBT may also be used in preparing for stressful
medical events or in facilitating positive health-related behaviour change.

Systemic or family-based approaches

Because people with chronic physical health problems often require additional caring
support from family or other carers, and because the illness can impact negatively upon
 224 ANGELA BUSUTTIL ET AL.

these relationships, it is recommended that families and carers are included in assess-
ment and clinical intervention, especially when people are suffering from both
depression and a physical health problem (NICE, 2009). This may be in the form of
family support or may require a formal systemic intervention. Other guidelines
including those for chronic fatigue and palliative care similarly acknowledge the value
of working with family systems in therapy, as social support is protective for physical
and mental health.

Third-wave CBT
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Third-wave CBT approaches comprise a heterogeneous group of treatments, including

acceptance and commitment therapy (ACT), and mindfulness-based cognitive therapy,
that place particular emphasis on compassion, acceptance and the importance of living
in the present moment.
ACT is an approach with a growing evidence base (Vowles and Thompson, 2011)
and is a particularly useful therapy in health settings. Rather than focus on negative
beliefs as in CBT, ACT advocates noticing and accepting thoughts and experiences,
including unwanted ones such as pain, without judgement. ACT aims to help the
individual clarify their personal values and to take action in line with them, increasing
psychological flexibility. It incorporates mindfulness – which emphasises the ability to
stay in the moment in an open and non-judgemental way (Dunford and Thompson,
2010) – and is particularly useful in giving patients and therapists the space to sit with
existential issues that cannot be fixed.

Integrative therapies
Integrative therapies such as cognitive-analytic therapy (CAT) have been used
beneficially in conditions such as diabetes (Fosbury et al., 1997).

Group approaches
Psychologists offer group therapeutic interventions with multi-disciplinary colleagues.
Physical, behavioural and medical approaches are considered within a self-management
framework (e.g. pain management (Hoffman et al., 2007), cardiac rehabilitation and
diabetes self-management groups).
Short-term therapeutic interventions may not meet the needs of those whose
conditions are long term and fluctuate. Patient support groups also play an important
role.

CASE STUDY

Assessment
Jack, 62 years old, retired, living alone, and with no previous history of mental
health problems, presented to one of us with depression and anxiety associated
with multiple health conditions. He had a stroke ten years ago but had recovered
 WORKING WITH PHYSICAL HEALTH PROBLEMS 225

physically. Mild cognitive problems persisted. He had hypertension, diabetes,

persistent pain from arthritis in his neck and concerns about dizziness and numbness.
He refused to take prescribed medication because of side effects. He sometimes
needed to get to the toilet urgently.
Jack articulated his concerns:

‘My doctor told me to come though I don’t understand what psychology can
do. I am not depressed, but I am coping with lots of difficulties. I want my
pain and this dizziness to stop. It’s frightening; I don’t enjoy going out any
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more. If my tests are normal what’s causing this? My wife died last year after
40 years of marriage. She really understood me. I worry my memory isn’t
what it was and I wish I could do all the things I used to do before I was ill.
I fear my son’s cancer will return. I can really talk to him but I get tired looking
after my grandchildren. I look after myself since my stroke. I attend a gym
and practise martial-arts learned in the army. I keep a journal as writing helps
me and helps with my memory. I go to church since my wife died. It gives
me hope I might see her again one day.’

Interested in self-management, Jack engaged readily. A personal and illness

history was taken, including exploration of illness beliefs. One of four brothers,
masculinity and athleticism were family values. If Jack fell over, he was told to get
up and carry on. This attitude to injury/illness was reinforced in army training with
a ‘no pain no gain’, ‘pain is just weakness leaving the body’ attitude. After leaving
the army Jack had a sedentary job; his weight increased, and his fitness decreased.
He used alcohol and smoked tobacco to manage work-related stress. On the day of
his stroke he experienced severe headaches but ignored the pain. He collapsed and
was rushed to hospital. Extensive rehabilitation followed weeks in intensive care.
Jack now feared having another stroke. No longer smoking or drinking, he
monitored every symptom ‘just in case’.
Jack was asked to keep a CBT thought diary over two weeks noting when
troubling symptoms occurred, and the thoughts, emotions and behaviours
associated with them. His diary reported difficulties with unfamiliar journeys.
Previously his wife had compensated for these difficulties by helping him plan.
He was hyper-critical of himself for his physical and cognitive difficulties.
Before going out Jack worried about potential symptoms. Concerns included:
‘Can I find my way there and back? Will I find a toilet in time? Will I feel dizzy or
have severe pain? Are these stroke symptoms?’ He fasted before going out to
avoid needing a toilet. He believed that if he needed help he could not ask
strangers, who would view him as an ‘old fool’.
Scores on the Hospital Anxiety and Depression Scale (Zigmond and Snaith,
1983) for both anxiety and depression were in the severe range. The Brief Illness
Perception Questionnaire (Broadbent et al., 2006) reflected a poor understanding
of illness, high concern about conditions and low perception of control. Memory
screening was normal.
 226 ANGELA BUSUTTIL ET AL.

Formulation
A generic model focusing on the following five areas was used with Jack to
formulate his difficulties (Dudley and Kuyken, 2006).

Presenting problems
• Confusion about health problems and how to manage them: dizziness and
numbness, pain, bladder and bowel symptoms, anxiety, depression. Symptoms
fearfully interpreted as possible sign of stroke.
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• Grieving (appropriate).
• Cognitive problems in public cause anxiety.
• Urgency to empty bowel and urinate when out, fasting to avoid going to toilet
(affecting diabetes?).

Predisposing problems
• Pre-existing diabetes, hypertension, arthritis, stroke.
• Family narrative about coping response to illness reinforced by army and martial-
arts training.
• Mild cognitive deficits following stroke affecting executive function (planning).

Precipitating factors
• Death of wife who had supported him practically and emotionally.
• Negative findings from medical tests (no explanation given for symptoms leading
to fear that something is being missed).
• Illness of wife and illness of his son led to preoccupation with health issues.

Perpetuating factors
• Beliefs: all symptoms have a physical cause; asking for help means weakness,
self-blame feeds depression.
• Coping behaviours: anxious monitoring of symptoms post-stroke maintains health-
related anxiety, not eating exacerbates dizziness.
• Meaning of symptoms: I am perceived by society as vulnerable and weak; I am
unsafe.

Protective factors
• Helpful coping: high self-efficacy active engagement in healthy behaviours: good
diet, regular exercise.
• Prepared to take an active part in self-managing his problems.
• Good social support.

Jack noted the interplay between physical health issues, cognitive problems and
mood. His own health issues, his wife’s death and his son’s illness had increased
awareness of his mortality and vulnerability. Ageing and vulnerability concerns
meant he feared going out and feared asking for help. He missed his wife’s support
in managing his health difficulties.
 WORKING WITH PHYSICAL HEALTH PROBLEMS 227

Drawing upon Folkman and Greer (2000, Figure 13.1), Jack recognised that
previous experience of stroke, and believing that physical problems always have a
physical cause, resulted in his appraisal of his symptoms as a threat: a sign of a
further stroke. This caused anxiety which in turn exacerbated existing physical and
cognitive problems. Symptoms he feared might indicate stroke included pain,
dizziness, numbness and bladder urgency.
Problem-based coping included dietary restriction. Emotion-based coping included
avoiding going out, resulting in not evaluating if his fears were based on fact.
Meaning-based coping viewed illness as personal weakness and such self-criticism
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contributed to depression.

Appraisal coping Event outcome Emotion outcome

Person Harm Problem- Favourable Positive

characteristics focused resolution emotion
coping

Threat
Distress

Event
Emotion- Meaning-
Challenge Unfavourable Positive
focused based
resolution emotion
coping coping

Sustains coping process

FIGURE 13.1 Coping

Source: From Folkman and Greer (2000). Copyright © 2000 John Wiley & Sons, Ltd.

Action plan
Jack wanted an explanatory framework to make sense of his physical, cognitive and
emotional problems; this would be provided through psycho-education. The bio-
psychosocial formulation enabled Jack to consider problems as challenges rather
than as threats. Jack wanted to learn alternative coping strategies which would be
effective in managing chronic illness.
CBT, an evidence-based approach for anxiety, depression and health anxiety,
which all feature in the formulation, was proposed to explore links between
cognitions emotions and behaviour. ACT and compassion-based approaches were
 228 ANGELA BUSUTTIL ET AL.

included to address both Jack’s wish to consider his life-goals at this transition point
in his life and his unhelpful self-criticism.
Jack wanted space to reflect on the impact of his wife’s death and his son’s
illness. Jack was grieving appropriately and was comfortable continuing with the
support which his church provided to explore existential issues.
Sessions were adapted to allow for Jack’s physical and cognitive difficulties by
having shorter appointments and providing written summaries.

Intervention
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Psycho-education
Jack was given information about anxiety, including hyper-ventilation, and was
surprised to learn that symptoms could include dizziness, tingling and numbness in
the fingers, as well as bladder/bowel urgency. Jack learned that restricting eating
contributed to low blood sugar levels (hypoglycaemia), symptoms of which include
anxiety and dizziness.
Looking at the pain-gate model (Melzack and Wall, 1967) enabled Jack to see
how psychological factors might exacerbate pain caused by arthritis in his neck.

CBT: cognitive reappraisal

Two possible explanations for Jack’s bodily symptoms were considered. The
first posited that these might indeed be warning signs of stroke; the second
alternative explanation was that anxiety increased existing physical problems
and that monitoring symptoms exacerbated anxiety, leading to a vicious cycle
(Figure 13.2).
Jack’s diary showed that he experienced symptoms daily but had never had a
further stroke. Factual information about stroke and anxiety was given. Reading
about this material enabled Jack to evaluate the two possibilities using facts.
He came to see that his symptoms did not relate to stroke and were either
increased by or perhaps in some cases caused by his anxiety response.

Behavioural experiments
Behavioural experiments were designed to test this hypothesis. First, Jack accepted
invitations to go out, challenging avoidance coping. He learned to notice, record and
then successfully challenge anxiety-related thoughts about stroke using the
information material given (see Table 13.1).
Jack began to practise breathing exercises he had learned in martial arts and
these controlled hyper-ventilation. Bowel/bladder urgency decreased, enabling him to
accept that anxiety contributed to this problem. He experimented with eating before
going out with no detrimental effects, and ‘dizziness’, which may have been
exacerbated by low blood sugar and diabetes, improved.
Jack had not understood the implications of post-stroke neuropsychological
testing, suggesting that he might have problems planning activity. Understanding
 Fear of
stroke
Symptoms
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Anxiety

FIGURE 13.2 One explanation for Jack’s bodily symptoms

this enabled Jack to effectively use problem- and emotion-focused coping. He

planned new journeys carefully and carried a mobile phone with emergency contact
numbers. Behavioural experiments revealed that when anxious, cognitive problems,
including memory, worsened. Managing anxiety resulted in some cognitive
improvements.

TABLE 13.1 Diary example

Situation Symptoms Belief Alternative Which belief is
more likely
Rushing to Dizziness, Could be I am rushing Symptoms
martial arts – need to empty another stroke and slightly improved so
Late!! bladder. – shouldn’t out of breath. alternative
ignore this. If this is the explanation
reason for is true.
dizziness, then Rushing and
my symptoms anxiety about
should improve being late
when I slow affected my
down. breathing which
made me feel a
bit dizzy.
 230 ANGELA BUSUTTIL ET AL.

Acceptance and commitment therapy (ACT)

Jack’s upbringing led him to view himself as worthless if inactive. He often did
too much and tiredness increased pain. Mindfulness techniques increased his
awareness of self-criticism. He practised being non-judgemental and self-
compassionate. This enabled him to give himself permission to use a behavioural
technique ‘pacing activity’ which helped reduce fatigue. Using ACT approaches,
Jack identified core personal values, including being a good father/grandfather.
He had been supporting his son by providing childcare previously undertaken by
his wife, which was physically exhausting. Jack had felt withdrawing would be
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unsupportive and show weakness. He identified alternatives which would

enable him to care for himself, while recognising his core values. Instead of after-
school childcare, he agreed to take the children to martial arts and help with
homework.

Systemic work
The intervention included a family session which proved helpful. Jack also shared
the formulation with his doctors.

Outcome
Jack learned to live with uncertainty about the exact cause of all of his symptoms
which had bio-psychosocial components. He found effective ways to cope,
reducing both symptoms and distress including anxiety and depression. Re-testing
(HADS, BIPQ) confirmed improvements in mood and decreased concerns about
illness. Reframing problems as challenges and avoiding self-blame allowed the use
of new coping skills with positive outcomes, which in turn sustained positive
coping. ‘Once I understood what was happening I could see how to cope‘. In
accepting his limitations and personal losses he acknowledged that despite ongoing
health problems, a good quality of life was achievable.

Team and indirect work

Psychologists in physical health settings are a scarce resource. The New Ways of
Working Initiative (BPS, 2007) encourages indirect working so that psychological
resources are used efficiently. Indirect activities like consultation, training and
supervision empower other health professionals to integrate a psychological
perspective in their practice, enhancing patient care without the psychologist
necessarily seeing patients directly. Medical staff may consult a psychologist for
help in managing patient problems like lack of adherence to treatment
recommendations, or helping distressed patients adjust to physical difficulties.
Psychologists also provide consultation over staff problems such as disagreement
within the team about how best to manage a patient (Hengeveld and Rooymans,
1983). In sharing a psychological formulation the psychologist promotes staff
 WORKING WITH PHYSICAL HEALTH PROBLEMS 231

understanding of the patient’s emotions and behaviour. This may enable the
team to think creatively about alternative ways of managing the patient’s
problems. Psychological consultation may be informal with psychologists sitting
in MDT meetings sharing psychological understandings of patients; or more
formal, where medical staff seek advice individually about a patient about whom
they have concerns. Psychologists integrated in multi-disciplinary teams may
have more opportunities to influence practice than external agents who may only
advise.
Psychologists perform an important role in training other professionals to use
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basic psychological skills with physical health patients. NICE (2004) guidelines on
cancer care recommend that all staff receive training in recognising psychological
distress and compassionate communication. Designated professionals like nurse
specialists may receive further training in using simple screening instruments and
basic psychological techniques. By providing regular ongoing supervision following
training, clinical psychologists ensure that newly learned psychological skills
continue to be applied appropriately.

CRITICAL ISSUES

Psychiatric diagnosis and physical health

The Diagnostic and Statistical Manual of Mental Disorders (DSM–V), published in May
2013, had several relevant changes in relation to physical health. One in particular
has received significant attention. ‘Somatoform disorders’ (DSM-IV) are replaced by
‘somatic symptom disorders’. Changes in criteria aim to ‘better reflect the complex
interface between mental and physical health’.
Somatic symptom disorder (SSD) is characterised by somatic symptoms alongside
one of the following (APA, 2013, p. 311):

1 Disproportionate and persistent thoughts about the seriousness of symptoms;

2 Persistently high level of anxiety re: health or symptoms;
3 Excessive time and energy devoted to symptoms or health concerns.

DSM-V does not require that the somatic symptoms be ‘medically unexplained’ as
did its predecessor, recognising that psychiatric disorders often occur with physical
health problems and that disproportionate or excessive concerns about the somatic
symptoms are indicative of psychiatric morbidity. SSD is likened to depression; ‘it can
occur in the context of a serious medical illness’.
It is argued that these changes promote comprehensive assessment and holistic care,
representing a move away from the mind–body separation indicated in DSM-IV.
The introduction of SSD has not been received without controversy. Opponents
of the changes highlight the subjective nature of the terms ‘disproportionate’ and
‘excessive’, on which diagnosis is based. It is not clear, critics argue, where ‘normal’
 232 ANGELA BUSUTTIL ET AL.

worrying ends and pathological anxiety begins. Similarly, there is no clarity regarding
what ‘good coping’ looks like, and when this becomes ‘excessive energy’ devoted to
symptoms. It is argued that SSD is overly inclusive and will greatly increase the numbers
of people with physical health problems diagnosed with psychiatric conditions.
Patient groups have raised concerns that there is greater scope for conditions which
are medically unexplained to be seen as ‘all in the head’ – a diagnosis of SSD in these
cases may lead to mental health referral with the exclusion of appropriate medical input
– shoring up mind–body dualism rather than dissipating it. At worst, this could lead
to misdiagnosis of mental disorder in people with physical health conditions which
are difficult to detect and diagnose.
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Clinical health psychology has a positive role here. People with physical health
problems are vulnerable to distress and mental health problems. Understanding the
context and impact of this are skills which clinical psychologists possess and can harness
in client-centred interventions aimed at reducing distress, whatever its label.

OUTCOME: LIZZIE’S STORY

The positive impact of my sessions was invaluable. Through some painful emotive
soul searching and honesty I was able to identify areas of my life that were still valuable.
I acknowledged the positive things I had managed to retain: my humour, courage,
determination and relationship with my son. I accepted that I deserved some happiness
and stopped grieving for my past life, and realised that life could still be enjoyable and
rewarding in different ways.
It was a joy and relief to see some clarity and take back control of my choices. I
reinstalled parts of my life I had locked away and forgotten: lovely clothes, jewellery and
lots of creative projects. My sessions provided me with invaluable strategies for
regaining self-esteem and pride in myself.
I know my illness is incurable but it no longer dictates my life. I am determined to
stride forward in strength and positivity.

CONCLUSION

Clinical health psychologists play a significant role in supporting people to cope with,
adjust to, and sometimes overcome, the impact of physical health problems. They teach
and support other healthcare staff to use psychological approaches in their work as well
as working with families and carers. The health and health economic benefits of this
type of work have been demonstrated; the challenge lies in finding the NHS resources
to further fund this important area of work.
 WORKING WITH PHYSICAL HEALTH PROBLEMS 233

KEY CONCEPTS AND TERMS

• Bio-psychosocial • Social support • Quality of life

model • Adjustment and • Stigma
• Psychoneuro- adaptation • Trans-diagnostic
immunology • Self-management health issues
• Multi-disciplinary approaches • Existential issues
working • Long-term conditions • Health care
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• Coping (LTCs) system

• Self-efficacy • Medically
• Locus of unexplained
control symptoms (MUS)

LEARNING OUTCOMES

When you have completed this chapter you should be able to:

1 Understand the psychological challenges that present within the context of

physical health.
2 Have an understanding of the psychological and societal issues which impact
upon how an individual lives with a physical health problem.
3 Have an understanding of psychological theories and models relevant to clinical
health psychology.
4 Have an understanding of treatment approaches used by clinical psychologists in
physical health settings, and the evidence base for these approaches.
5 Understand how assessment, formulation, intervention and evaluation might be
used by a psychologist working on a specific case.
6 Be able to provide a critical appraisal of different psychological intervention
approaches used in physical health settings.

SAMPLE ESSAY TITLES

• How do psychological factors play a role in physical health conditions?

• What are the similarities and differences between clinical psychology and clinical
health psychology?
• What is the role of a clinical health psychologist in a multi-disciplinary team?
• Psychological adjustment is key to positive outcomes in physical health. Discuss.
 234 ANGELA BUSUTTIL ET AL.

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 14 Working with people
with dementia
Jane Shepherd, Sally Stapleton and
Maureen Jeal
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MAUREEN’S STORY

I am 67 years old and live with my husband Brian. I’ve always liked to help others. I’ve
always been a worker and I like to keep busy. Alzheimer’s stopped me working. When I
was first told I had Alzheimer’s three or four years ago, I thought, ‘don’t give in, carry
on’. You’ve got to have a laugh. I like to laugh with the grandchildren. I’m always saying,
‘don’t ask me, I’ve got Alzheimer’s’. My memory is going fast. I get frustrated when I
lose things. Sometimes I don’t like being like this, I didn’t ask for this. When I get upset
with the Alzheimer’s, I feel as if I’ve done something wrong and I’m no good to anyone.
But I’m a lot happier than I was. I get on well at the club. They’ve brought me on a good
treat. They appreciate what I do. I’m more like one of the staff. If someone’s struggling
I’ll help them. I set the table, I do the napkins, I help with cooking. I lay the table. I
interact with the residents. I help them with their eating. I like to be needed, I like to
have purpose. As long as I have the family and Brian, I can cope with the Alzheimer’s.
Brian helps me remember things. He does the cooking. I help out a bit, with the
housework. Brian and my family are fantastic, they’ve done so much for me. They give
me love.

SUMMARY

Maureen’s story shows that, with the right care and support, people with dementia can
continue to lead active and fulfilling lives. This chapter highlights the role clinical
psychologists have in providing psychological interventions that enable people with
dementia to live as well as they can with their dementia. As you will see from this chapter,
the growing influence of psychological approaches has been crucial in guiding the
expansion of practice and research in dementia care. The chapter will cover a range of
psychological theories and interventions which focus upon the experiences of people with
 WORKING WITH DEMENTIA 237

dementia and their carers/families. The evidence base for these theories and interventions
is briefly reviewed. The chapter will also provide case examples to demonstrate how
psychologists put their knowledge and skills into practice when working with individuals,
families and multi-professional staff teams in care environments. Finally, it will
outline the debates and challenges in the shared endeavour of aiming for excellence in
dementia care.

INTRODUCTION
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The National Dementia Strategy defines ‘dementia’ as ‘a syndrome which may be

caused by a number of illnesses in which there is progressive decline in multiple areas
of function, including decline in memory, reasoning, communication skills and the
ability to carry out daily activities’ (Department of Health, 2009, p. 15).
‘Dementia’ is an umbrella term. There are over 100 conditions which cause
dementia (NCCMH, 2007). The most common types are Alzheimer’s disease and
Vascular dementia. Alzheimer’s disease is a condition involving protein ‘plaques’ and
‘tangles’ which lead to the death of brain cells. Vascular dementia occurs following
damage to the blood-vessels (vascular system) within the brain; for example, following
a series of small strokes. Brain cells die due to the lack of oxygen supply. The
Alzheimer’s Society provides an excellent range of fact sheets on different types of
dementia (see www.alzheimers.org.uk).
There is currently no cure for the conditions that cause dementia. However, much
can be done to improve the quality of life of people with dementia, from assisting
with the diagnostic process, to supporting people at the end of their lives (Department
of Health, 2009). Clinical psychologists help us understand the specific experiences of
each person with dementia and those who support them. Two people with identical
diagnoses may have completely different experiences of living with dementia. Their
experiences depend just as much upon factors such as their own life experiences and
the quality of support that they receive from others, as it does upon the extent of
neurological difficulties.

DIAGNOSIS

DSM-V includes types of dementia under the category of ‘Major and mild neuro-
cognitive disorders’.
For a diagnosis of a ‘major neurocognitive disorder’, there needs to be evidence of
significant decline in one or more of the following cognitive abilities:

• Complex attention (e.g. keeping focused despite distractions).

• Executive function (e.g. planning and decision making).
• Learning and memory (e.g. remembering recent events).
• Language (e.g. naming, speech production and comprehension).
• Perceptual motor (e.g. object recognition, coordinating actions).
• Social cognition (e.g. considering others’ feelings and wishes).
(APA, 2013)
 238 JANE SHEPHERD ET AL.

There are specific criteria for different conditions. For example, the criteria of ‘Major
neurocognitive disorder due to possible Alzheimer’s disease’ requires clear evidence
of a gradual decline in learning and memory and a decline in at least one other cognitive
domain.
Evidence of cognitive difficulties from neuropsychological assessment (this involves
carrying out a number of standardised tests that tap different aspects of cognitive
processing and reasoning) or another ‘quantified clinical assessment’ is preferable (APA,
2013). Therefore, clinical psychologists (with neuropsychology training) can assist with
the diagnostic process.
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WHAT ARE THE TYPES OF PSYCHOLOGICAL DIFFICULTIES

THAT MAY OCCUR IN DEMENTIA?

Dementia has a profound impact upon the lives of people with dementia and those
around them. As you would expect, each person’s experience is unique, and people
with the same type of dementia and similar brain damage will experience and respond
to their dementia in different ways. Dementia can impact directly upon the following
factors.

Mood and everyday activities

Maureen described the everyday challenge of being unable to do things the way she
used to. Cognitive difficulties such as poor memory and visual perception problems
often account for this. She spoke about anxiety and lowered self-esteem and
confidence. People with dementia may also experience depression and a range of
negative feelings in response to their illness, such as anger and frustration.

Communication and relationships

People with dementia can feel isolated and experience a lack of belonging. This may
be as a result of communication difficulties and low confidence but may also be a
consequence of how they are perceived and treated by others. There may be difficulties
within the caregiving and/or family relationships as the family struggle to adjust to the
changes in roles and usual ways of interacting.

Psychological and behavioural distress

As dementia progresses, people with dementia can show distress or engage in
behaviours that others find upsetting. One example is being agitated or angry when
someone is trying to help with dressing or eating. These episodes can be distressing
for the person with dementia and others. The causes of these behaviours are usually
complex and often relate to a person’s attempts to address an unmet need. Typical
causes are pain, boredom and frustration.
 WORKING WITH DEMENTIA 239

Carers and families

Caregiving has been associated with a range of experiences, including high levels of
distress, depression and physical ill health as well as positive aspects such as satisfaction
and meaning in one’s role (Carbonneau et al., 2010).
Families can go through difficult periods of not knowing how best to support the
person with dementia. There may be differences of opinion among family members
or with professionals about responding to concerns about a person’s safety or behaviour.
Family members may experience guilt and grief when making difficult decisions in
the best interests of the person with dementia and/or the main caregiver, such as going
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into residential care.

LIVING WELL WITH DEMENTIA

Maureen has maintained her well-being with the loving support of her family, and
she has actively developed and has been encouraged to develop positive and valued
social roles at the club. She showed awareness of her difficulties and her coping through
adopting a positive outlook, using humour and keeping active.
Drawing upon interviews with people with dementia, Clare (2002) provides a useful
framework for ways of coping with dementia, on a continuum from self-maintaining
to self-adjusting. Maureen’s story illustrates the self-adjusting style of openness and
flexibility in adapting to the challenges of dementia through attending a club with
people in a similar situation and accepting others’ help. Those taking a more self-
maintaining position try to maintain their identity and lifestyle as normal and downplay
the impact of the dementia. Both positions can be useful in enabling people with
dementia to lead meaningful lives.

EPIDEMIOLOGY OF DEMENTIA

The Alzheimer’s Society’s 2013 report estimated there to be 800,000 people with
dementia in the UK. This figure is anticipated to rise to over a million by 2021 and
to 1,700,000 by 2051. Dementia is most prevalent in older people but there are 17,000
people with dementia in the UK who are under the age of 65.
The following are the prevalence rates of dementia in different age groups:

• 40 to 64 years: 1 in 1,400
• 65 to 69 years: 1 in 100
• 70 to 79 years: 1 in 25
• 80+ years: 1 in 6.

The proportion of people with dementia doubles for every five-year age group, with
one-third of people aged 95 and over experiencing dementia.
At the present time only 44 per cent of individuals with dementia in England, Wales
and Northern Ireland receive a diagnosis (Alzheimer’s Society, 2013). There is
currently a drive to improve dementia care services and research, which includes
increasing access to diagnostic services (Department of Health, 2012).
 240 JANE SHEPHERD ET AL.

AETIOLOGY OF DEMENTIA

Neurological difficulties do not fully explain the diversity in people’s experiences of

living with dementia. This section will consider the risk factors for developing
dementia and then discuss factors that are related to well-being.

Risk factors
We do not always know why certain individuals develop dementia. Known risk factors
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include smoking (Ott et al., 1998), excessive alcohol consumption (Saunders et al.,
1991), obesity (Kivipelto et al., 2005), diabetes (Biessels et al., 2006), hypertension
(Feigin et al., 2005) and raised cholesterol (Jick et al., 2000). A small proportion of
people develop dementia due to a genetic-related factor (Morris, 2005), for example,
familial autosomal dominant Alzheimer’s disease. The full version of the NICE/SCIE
Clinical Guideline 42 (NCCMH, 2007) provides an excellent overview of risk factors.

A biopsychosocial model for understanding the experience

of living with dementia
How a person with dementia feels, thinks and acts is influenced by a number of
biological, psychological and social factors. This is outlined in Figure 14.1.
This model is used by clinical psychologists to formulate an understanding of factors
associated with well-being and distress. For example, a staff carer tells you that Raj, a
gentleman with dementia, screams and hits out at staff members every time they try
to assist him with personal care. It may be thought that Raj’s behaviour is the direct
result of dementia and that there is nothing that can be done to help. However,
drawing upon the bio-psychosocial model (Figure 14.1), we find that Raj has always
been shy and private. He may have a need to continue to maintain as much privacy
as possible but he is unable to tell staff that this is due to language difficulties. Raj’s

Neurological impairment –
cognitive difficulties and abilities

Health and physical fitness

(including mental health, possible
The experience of undetected pain, side effects of medication)
living with dementia
Biography (life story)

Personality

Psychosocial and physical environment

FIGURE 14.1 Bio-psychosocial model of dementia

Source: Kitwood (1997), James (1999), NCCMH (2007).
 WORKING WITH DEMENTIA 241

behaviour in this situation could therefore be formulated as an attempt to communicate

an unmet need.
Unmet needs and psychological distress
The bio-psychosocial model may be used to identify a person’s needs, whether the
need relates to neurological difficulties, a health need or a need related to their own
personal life experiences. There is a general consensus that psychological distress, often
expressed through a person’s behaviour, is related to unmet needs (British Psychological
Society, 2013).
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Models for formulating unmet psychological needs

The bio-psychosocial model has been expanded to formulate factors related to
psychological and behavioural distress (James, 2011). Crucially, a care team is
encouraged to record a person’s vocalisations (thoughts), appearance (feelings) and
behaviours, alongside information about what was happening at the time, to help
identify triggers. Applying this to Raj, the member of staff might record that the trigger
for Raj starting to scream was during personal care. At these times he looked frightened
in his appearance. His vocalisations were that he screamed ‘no’ and his behaviour was that
he hit a member of staff on the arm when they tried to remove his clothes.
Figure 14.2 outlines the psychological needs for comfort, identity, attachment,
occupation and inclusion, with love as a central need (Kitwood, 1997). We can use
this model to understand which psychological need may not be being met. For

ORT
MF IDE
CO NT
IT
Y
IN C LU SIO N

LOVE
ENT
HM
AC
TT

A
OC
C U PA
TIO N

FIGURE 14.2 The five psychological needs of people with dementia

Source: Kitwood (1997); reproduced with kind permission of the Open University Press/McGraw-Hill
Education). Maureen’s description of the importance of her family’s love validates the central need
for love.
 242 JANE SHEPHERD ET AL.

example, we might formulate that Raj screamed and hit out at staff members due to
his comfort needs not being met. We could therefore formulate that staff members
need to help Raj feel safe, secure and comfortable if he needs assistance with personal
care.
The potential to support or undermine psychological needs
during interactions
People with dementia are greatly affected by how they are treated by others. The terms
‘positive’ and ‘malignant’ social psychology have been used to illustrate this (Kitwood,
1997). Examples of malignant social psychology are when an individual experiences
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depersonalising treatment such as being treated like a ‘child’ or an ‘object’. This can
undermine a person’s psychological needs. Examples of a positive social psychology
are when an individual experiences ‘warmth’, ‘respect’ and ‘genuineness’. These can
help meet an individual’s psychological needs (British Standards Institution, 2010).

THEORY AND EVIDENCE FOR PSYCHOLOGICAL

INTERVENTIONS IN DEMENTIA CARE

This section will cover the range of psychological and psychosocial approaches for
people with dementia and their carers from early through to severe dementia. This is
a rapidly growing research field and the interventions described below are
recommended in the NICE-SCIE dementia guidance (NCCMH, 2007) and/or the
BPS guidance (2013).
Psychologists deliver three main types of interventions:

(1) To support well-being and cognitive abilities in early to moderate dementia and prevent later
difficulties.
Psychologists work with people with dementia and their carers to make the most
of their remaining cognitive abilities such as memory and language. This work is often
based on neuropsychological assessment to explain why the person may be having
particular problems with everyday activities such as dressing or understanding what is
being said.
Cognitive stimulation therapy is a group intervention to enhance cognitive and
social functioning through a range of activities (for example, a review of newspaper
stories) and discussion. It also involves reality orientation which focuses on orientation
to time, person and place, and reminiscence therapy which focuses on past memories.
There is strong evidence for the effectiveness of cognitive stimulation therapy on
cognition, mood and behaviours that challenge (e.g. Spector et al., 2010).
Cognitive rehabilitation is an individually tailored approach to achieve everyday
activities such as taking tablets at the correct time or walking outside independently.
People are encouraged to use learning strategies such as memory aids and reduce the
number of errors during learning. Single case studies show positive outcomes with goal
performance and satisfaction (Clare, 2010).
Psychologists use life history work such as life reviews and life stories to encourage
people to reflect on positive and significant life experiences, often with carers or family.
An example of a life review is to ask the person and family to recall how they dealt
 WORKING WITH DEMENTIA 243

Reduction in inappropriate use of antipsychotic

medication: Time for Action
Anti-psychotics have been used in dementia to treat behaviours such as
‘agitation’ and ‘aggression’ because of their sedative properties. They are
also used for delusions and hallucinations. An influential report, Time for
Action (Banerjee, 2008), found that anti-psychotic medication was often used
as a first-line treatment despite evidence that anti-psychotic drugs have
limited effect and can cause significant harm to people with dementia,
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FOCUS 14.1

including strokes and death. The government has adopted Banerjee’s

recommendations for a reduction in the use of anti-psychotics and an
increase in the use of alternative non-pharmacological approaches. A recent
Alzheimer’s Society (2013) report showed a 52 per cent reduction in the
number of inappropriate prescriptions for anti-psychotics for people with
dementia.

with past difficulties and use their learning and experiences to guide them in their
present situation. Life stories can take a number of forms, including conversations, life
story-books, collages and reminiscence boxes. Reminiscence therapy is usually deliv-
ered as a group intervention for people to share memories and common experiences.
Reminiscence and life history work can reinforce the person’s sense of self, improve
close relationships and promote communication and enjoyable activity (e.g. Woods et
al., 2005). See Bruce and Schweitzer (2008) for a comprehensive description of life
history work.
Psychologists often work with couples and families in order to improve the com-
munication and interactions in the interests of the person with dementia. From our
clinical experience, common themes in this work include facing losses and changes in
relationship roles, the impact of family experience of dementia and illness and preparing
for the future. There is good evidence that involving carers and families in early
interventions can improve the well-being of both the person with dementia and their
carer as well as delay later nursing home admissions (e.g. Smits et al., 2007).

(2) To improve mood disorders for people with dementia and carers.
As described in the psychological difficulties section, people with dementia and carers
can also have anxiety and/or depression arising from the experience of dementia or
the demands of being in a caregiving role. If so, they may benefit from psychological
therapies, including cognitive-behavioural therapy, which is recommended in NICE-
SCIE guidance (NCCMH, 2007), with research trials underway (Spector et al., 2012).

(3) To address psychological and behavioural distress in moderate to severe dementia.

As described above, psychologists use bio-psychosocial assessment and formulation to
explain why the distress and behaviours may be occurring in the context of the person’s
dementia, life history and social and physical environment. There may be a range of
 244 JANE SHEPHERD ET AL.

causes including pain, misinterpreting things and people’s actions, past trauma and
specific interactions with caregivers. Psychologists draw on a range of theories,
including neuropsychological, cognitive-behavioural, psychodynamic (especially
attachment) and systemic frameworks. Case studies below further illustrate the use of
clinical formulation in practice.
There is best practice guidance (BPS, 2013; NCCMH, 2007) and promising
research (Moniz-Cook et al., 2012) for individualised psychological formulation-led
approaches. An influential RCT study on person-centred interventions in care homes
found a significant reduction in the use of anti-psychotic medication with regular input
from a trained clinician (Fossey et al., 2006).
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Dementia care mapping (DCM) is recommended for improving the well-being of

people with dementia within care settings (BPS, 2013). This is a structured observation
framework for assessing the factors associated with well-being and distress, including
interactions among people with dementia and care staff. DCM has been shown to
significantly reduce levels of agitation in a cluster RCT (Chenoweth et al., 2009).

CASE STUDY

Mrs Sylvia Peterson was admitted to an inpatient ward, having become severely
distressed following the experience of visual hallucinations. Sylvia and her family
reported that they wanted advice and support with the visual hallucinations so that
she could return to living at home as soon as possible. I (SS) agreed to meet with
Sylvia and her family.

Assessment
I initially met with Sylvia individually to find out more about her as a person, including
her life history and strengths. I wanted to explore the emotions she experienced
during the hallucinations to see if there were any connections with her life history.
I also wanted to explore any potentially unmet psychological needs.
I also met with her husband and son to understand their perspective. I was
interested in finding out how they responded to her when she was experiencing
hallucinations and distress. I also wanted to find out about their strengths and how
they were coping in their relatively new caring roles. I also read Sylvia’s health
records and talked to members of the care team, as I wanted to obtain as much
information as possible about factors that might be relevant to the bio-psychosocial
formulation.

Formulation
Neurological impairment
Sylvia told me that she had dementia. Her family said that she had been given a
diagnosis of Dementia with Lewy Bodies. In her health records, I saw that a
neuropsychological assessment indicated that she had difficulties with memory,
 WORKING WITH DEMENTIA 245

visuo-spatial and executive functioning. Her language skills, however, were a

strength. Her son told me that people outside of the family would often not realise
that she had any difficulties, as she was able to hold a good conversation. This was
also my experience.

Health and physical fitness

Sylvia told me that sometimes the hallucinations she experienced were of animals or
children and did not worry her too much. However, at other times she saw ‘nasty
people’ who were coming to beat her up. She reported that she thought that they
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were not real, but it was difficult to know, especially when she was feeling really
frightened. On further exploration, she said she was scared of being beaten again, as
she experienced this as a child. During her first two weeks on the ward, the nursing
team reported that there were times when she looked extremely frightened and
would try to hide behind furniture or approach staff members, asking for help and
‘clinging’ to them. At other times, if alone, she sometimes screamed. These
observations were reflected in her scores on the Cohen-Mansfield Agitation scale
(CMAI: Cohen-Mansfield et al., 1989).
Sylvia had experienced significant negative side effects of anti-psychotic
medication when they were prescribed to treat visual hallucinations in the past. Her
family and the care team also told me that she experienced urinary tract infections
(UTIs), especially when not drinking enough fluids, and that she sometimes
experienced pain due to a previous back injury. The Pain Assessment in Advanced
Dementia (PAINAD: Warden et al., 2003) identified that she experienced pain on a
regular basis, although she was not always able to report this. Instead staff members
were reliant on observing for signs, such as grimacing and holding her back.

Life history
Sylvia told me that she had an unhappy childhood and was badly beaten by her
mother when she did something wrong. She met her husband at age 17. They
married 18 months later and went on to have a son. She described that they had a
happy life together, except for the usual ups and downs, and felt very proud of their
son. She worked in a shoe shop for 25 years. Her main interests included gardening
and cooking, but she said she liked to ‘have a go at anything’. She told me that she
liked to be called by her first name.

Personality
Sylvia reported that she liked to keep herself to herself and did not wish to cause any
problems for anyone. Her family described her as a kind and caring person who was
quite shy.

Psychosocial environment
Sylvia’s family described that they did not know what to do when she experienced
hallucinations. They had tried telling her that the hallucinations were not real, but this
seemed to make things worse. She became more distressed and shouted at them,
 246 JANE SHEPHERD ET AL.

which made them feel stressed, angry and helpless. They described feeling ‘at the
end of their tether’ but also ‘desperately wanting to know what to do to help’.
Her family reported that she had stopped engaging in her interests of gardening
and cooking. This was reflected in her scores on the Quality of Life in Alzheimer’s
Disease Scale (QOL-AD: Logsdon et al., 2002).

Summary of the bio-psychosocial formulation

Sylvia and her family became very distressed when Sylvia experienced hallucinations.
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She was more at risk of hallucinations due to a diagnosis of Dementia with Lewy
Bodies, in addition to her tendency to misperceive objects (visuospatial difficulties).
Her hallucinations emerged at the time of her diagnosis, but she was more likely to
experience distressing hallucinations when physically unwell or in pain. She did not
wish to worry people too much, and so she often would not report if she felt
physically unwell or in pain. This led to these difficulties not being treated promptly.
Her life history of being beaten as a child by her mother almost certainly influenced
her perceptions of the hallucinations she experienced, particularly if she was already
distressed. The responses from her family (her psychosocial environment) led to
arguments with her, resulting in further distress and anger. Her distress influenced
her perception of the hallucinatory experiences. Her quality of life was low due to the
impact of the difficulties on her family relationships and her limited engagement in
meaningful activities.
Despite these difficulties, Sylvia and her family had a number of strengths. The
most striking was their close relationship. Her family described Sylvia as a very kind
and caring person who was able to form positive relationships with others. She was
also able to talk about her interests and try out new things. As a family, they were all
open to thinking together in a psychological way and were open to advice from other
members of the care team.

Individual therapeutic sessions

The formulation led me to offer Sylvia some short individual therapeutic sessions on
the ward to further explore the links she had started to make between hallucinatory
experiences and her childhood experiences. I offered her individual sessions initially,
as I was not sure how much she had discussed her childhood experiences with her
family. The sessions were based on a simplified cognitive-behavioural framework, as
recommended in the NICE-SCIE guideline (NCCMH, 2007) for people with dementia
who experience emotional difficulties. The key aim of the sessions was to work
towards a joint understanding of her thoughts, feelings and actions when she
experienced a hallucination. She engaged very well in the sessions.
Sylvia told me that her family were aware of her childhood experiences and she
decided she wanted to include her family within future therapeutic sessions so that
together they could find ways of reducing the amount of distress they were all
experiencing.
 WORKING WITH DEMENTIA 247

Therapeutic sessions with Sylvia and her family

Sylvia’s family were keen to think about the potential links between her past and
present experiences. I was therefore hopeful that collaborating on the formulation
together, as a family, would help them find useful ways of supporting one another.
A plan of support at times of distress was agreed. This was based on validation
therapy (Feil, 1993) whereby a person’s feelings take priority. It was agreed that,
rather than trying to help her see that she was having a hallucination or pretending
that they could see what she was perceiving, they would instead validate her
feelings and provide her with a sense of security and comfort. For example, they
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could say, ‘I can see you are really frightened, I’m going to stay with you and make
sure that you are safe’, or ‘It’s okay, I’m here with you’. A therapeutic letter was
written as a reminder of the discussion.

Work with the care team:

With Sylvia’s permission, I agreed to share the key themes of the formulation with
the multi-disciplinary team to help identify ways of preventing and responding to
times when she was distressed. I also sought the team’s advice. The ward doctor
prescribed regular paracetamol for pain. The primary nurse gave advice on prevention
of recurrent UTIs. The OT advised on meaningful engagement and gentle exercise to
reduce back pain and improve her mood. Sylvia was referred to the cognitive
stimulation therapy group to further promote quality of life.

Outcome
Sylvia reported feeling less distressed by the hallucinations, although she still
reported seeing ‘nasty people’ at times. Her family reported that they felt much more
able to support her during these times. They all reported a shared understanding of
the impact of previous abusive experiences and said it made it easier to offer comfort
and support.
The ward team reported finding it easier to support Sylvia at times of distress, in
addition to feeling more able to support her general well-being on the ward. Her
scores on the QOL-AD, CMAI and PAINAD indicated substantial improvements.

TEAM WORKING/INDIRECT WORK

Clinical formulation and consultation

As described above, psychologists work with colleagues and care staff to understand a
person’s distress and complex behaviour in psychological ways, either as an alternative
to or to complement the use of medication. They use clinical formulation to broaden
staff members’ understanding of communication and behaviour. This can help staff
resolve differences of opinion about what is best for the person with dementia and
 248 JANE SHEPHERD ET AL.

explore ways to respond to distress and behaviour that challenges. The following
example illustrates this work:

Bob was an 84-year-old man in a residential setting. Staff reported him making
sexually inappropriate advances towards them when helping him with his washing
and dressing. A few staff sometimes told him off and other staff reported that this
resulted in ‘aggressive behaviour’. During the formulation session, the psychologist
helped the staff gather information from Bob’s personal history, type of dementia
and their interactions with him. The aims were to encourage staff to be curious
about what might be causing Bob’s behaviour and to reflect on their role in helping
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to meet his needs in helpful ways. This information sharing revealed that Bob was
a happily married man who had been faithful to his wife and so sexual overtures
to others was out of character and would normally be embarrassing for him. He
was likely to be missing the intimacy with his wife. Due to experiencing
‘Frontotemporal dementia’ he was more likely to be disinhibited. He might
misperceive the close physical contact with staff around personal care as a sexualised
act. The staff began to empathise with Bob’s situation and a few commented that
they might have been ‘a bit harsh’ with him. The psychologist helped them devise
a range of interventions; they reflected on whether they might talk with Bob about
missing his wife, they discussed ways of addressing boredom and inactivity, and
they identified the best ways of approaching and communicating with him during
personal care tasks.

Staff and service development

Clinical psychologists working in dementia services support staff learning and
development, drawing upon psychological perspectives and clinical research. Topics
include assessment of cognitive functioning, neurological causes of behaviour that
challenges and working with families. They also advise on service design and evaluation
which includes specific interventions and clinical outcomes.

CRITICAL ISSUES

Responding to the increasing numbers of people with

dementia
Dementia is both a national and international priority owing to growth in ageing
populations and the related significant increase in the prevalence of dementia. The G8
Dementia Summit in 2013 sent a global message about the need for collaborative action
on research and treatments. It set an ambitious target of identifying a cure or disease-
modifying therapy by 2025. The UK government pledged to double research funding
by 2025. The hopes for people to ‘live well with dementia’ need to be backed up by
properly funded and resourced services. Research into both ‘cure’ and ‘care’ is
seriously underfunded, with the UK government currently investing eight times less
in dementia than in cancer research (Alzheimer’s Society, 2013b).
 WORKING WITH DEMENTIA 249

Public awareness
There is greater recognition that society can make a difference to the lives of people
with dementia through dementia-friendly communities (Alzheimer’s Society, 2013a).
Loneliness and social isolation are real issues for people living on their own, with 62
per cent of 500 people with dementia surveyed reporting feeling lonely (Alzheimer’s
Society, 2013a). There is also the risk of double discrimination within services and
society due to negative attitudes about both ageing and dementia. Real progress will
be made when people with dementia are enabled to maintain their involvement and
contribution to their community (NICE, 2013).
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Earlier diagnosis and support

Dementia diagnosis rates are shockingly low (Alzheimer’s Society, 2013a). Less than
half of the 800,000 people living with dementia in the UK have a diagnosis. Without
this, they are denied access to support, information and potential treatments that can
help them to live as best they can with dementia.

Quality of care
While there are many excellent services around the country, provision is patchy and
there are real challenges in driving up the quality of care from acute hospitals through
to people’s homes. Attention needs to be given to those with more severe dementia
and complex needs as well as those with early dementia. Guidance such as the National
Dementia Strategy (Department of Health, 2009) have recognised the challenges facing
services to meet the full range of needs of people with dementia and their carers. One
key way of improving quality is to increase the involvement of people with dementia
and their carers in the delivery and evaluation of services.

Support for carers

There is a serious problem of inadequate recognition and support for people who care
for people with dementia. Two-thirds of people with dementia live in the community
and it is estimated that family carers contribute work to the value of £8 billion
(Alzheimer’s Society, 2013a); yet much of the caring is hidden and unpaid carers can
struggle on their own with insufficient help.

Abuse and poor practice

There have been shocking reports of poor care and abuse of older people in some
hospitals and care homes. Strong leadership is required to address the staff and
organisational barriers to good care. Research highlights barriers to good care such as
poor leadership, high staff turnover, low pay and staffing levels, and lack of supervision
(Bowers, 2008).
 250 JANE SHEPHERD ET AL.

CONCLUSION

One of the greatest challenges of our time is what I’d call the quiet crisis, one that
steals lives and tears at the hearts of families, but that relative to its impact is hardly
acknowledged.

This statement by Prime Minister David Cameron at the G8 Summit in 2013 is a

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powerful invitation to focus upon the needs of people living with dementia and their
families. We hope this chapter has shown that, despite the lack of a cure, psychologists
can play a key role in spearheading best practice interventions and models of care that
can make significant improvements to the quality of life of people with dementia, as
well as their families and carers.

CONCLUSION TO MAUREEN’S STORY

Experience of psychological intervention as told by Kate, Maureen’s daughter.

‘Mum was a bit anxious about seeing you (JS) at first. She is not one to come out
with how she feels. She didn’t want to cry or feel anxious. We were surprised at
how much she said. She let her emotions out talking to you. You were trying to
get her to understand how she feels, how her worry about the Alzheimer’s affected
her stomach pain. We wanted advice on whether we were doing what we should
be doing. We got so much from it. We understood that it was okay for Mum to
feel low about having Alzheimer’s. I spoke to the club about how they could help
Mum. They got her helping out and got her a task sheet. We got a daily checklist
together to assist Dad with housekeeping. The grandchildren made a nice photo
album. Everything we talked about with you we discussed as a family. We all
support each other.’

KEY CONCEPTS AND TERMS

• Dementia • Unmet psychological • Dementia-friendly

• Carer/caregiver needs communities
• Person-centred care • Alzheimer’s Society • Psychological and
• Bio-psychosocial • National Dementia behavioural distress
model Strategy • Neuropsychology
 WORKING WITH DEMENTIA 251

LEARNING OUTCOMES

When you have completed this chapter you should have an understanding of:

1 The range of difficulties that may be experienced by people with dementia and
their families/carers.
2 The bio-psychosocial models that are used to inform our understanding of the
experiences of people with dementia.
3 The evidence base for interventions used to increase well-being and quality of
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life in people with dementia and their families/carers.

4 The work of clinical psychologists in their use of assessment, formulation,
intervention and evaluation with people with dementia, their families and care
staff.
5 The key issues relating to the well-being of people with dementia and their
family/carers and the challenges of driving up the quality of dementia care in
services.

SAMPLE ESSAY TITLES

• Can people with dementia benefit from psychological interventions?

• How can helping carers help people with dementia?
• What are ‘good outcomes’ for people with dementia?
• How can clinical psychologists help care staff resolve difficulties that relate to the
behaviour of a person with dementia?

REFERENCES

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info.php?documentID=1111(accessed 27 August 2013).
American Psychiatric Association (APA) (2013). Diagnostic and Statistical Manual of Mental
Disorders Fifth Edition DSM-5. Arlington, VA: American Psychiatric Association.
Banerjee, S. (2008). The use of antipsychotic medication for people with dementia: Time for
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Biessels, G.J., Staekenborg, S. and Brunner, E. (2006). Risk of dementia in diabetes mellitus:
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Bowers, B. (2008). A trained and supported workforce. In M. Downs and B. Bowers (eds),
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British Psychological Society (2013). Alternatives to Antipsychotic Medication: Psychological approaches

in managing psychological and behavioural distress in people with dementia. Leicester: British
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British Standards Institution (2010). PAS 800: 2010. Use of dementia care mapping for improved
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Chenoweth, L., King, M.T., Jeon, Y.H., Brodaty, H., Stein-Parbur, J., Norman, R.M., Haas,
M. and Luscombe, G. (2009). Caring for aged dementia care resident sudy (CADRES) of
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Clare, L. (2002). We’ll fight it as long as we can: Coping with the onset of Alzheimer’s disease.
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––– (2010). Goal-oriented cognitive rehabilitation for people with early stage Alzheimer
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Department of Health (2009). Living Well with Dementia: A national dementia strategy. London:
Department of Health.
––– (2012). Prime Minister’s Challenge on Dementia: Delivering major improvements in dementia care
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Feigin, V., Ratnasabapathy, Y. and Anderson, C. (2005). Does blood pressure lowering
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Feil, N. (1993). The Validation Breakthrough. Cleveland: Health Professions Press.
Fossey, J., Ballard, C., Jusczak, E., James, I., Alder, N., Jacoby, R. and Howard, R. (2006).
Effect of enhanced psychosocial care and antipsychotic use in nursing home residents with
severe dementia: A cluster randomised trial. British Medical Journal, 23 March.
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Jick, H., Zornberg, G.L., Jick, S.S. and Seshadri, S. (2000). Statins and the risk of dementia.
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Kitwood, T. (1997). Dementia Reconsidered: The person comes first. Buckingham: Open University
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Kivipelto, M., Ngandu, T. and Fratiglioni, L. (2005). Obesity and vascular risk factors at midlife
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older adults with cognitive impairment. Psychosomatic Medicine, 64, 510–519.
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Moniz-Cook, E., Swift, K., James, I., Malouf, R., De Vugt, M. and Verhey, F. (2012). Function
analysis-based interventions for challenging behaviour in dementia. Cochrane Library, 2.
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100–117.
National Collaborating Centre for Mental Health (NCCMH) (2007). Dementia: The NICE-
SCIE Guideline on supporting people with dementia and their carers in health and social care (Full
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Ott, A., Slooter, A.J. and Hofman, A. (1998). Smoking and risk of dementia and Alzheimer’s
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(2007). Effects of combined intervention programmes for people with dementia living at
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of the Pain Assessment in Advanced Dementia (PAINAD) scale. Journal of the American
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Woods, B., Spector, A.E., Jones, C.A., Orrell, M. and Davies, S.P. (2005). Reminiscence
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 15 Working in
neuropsychology
Angela Reason, Anna Healey
and Jan Rich
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JAN’S STORY

I am 70 and retired at 63 to help look after my mother. My working life started at a very
early age when I worked at a local riding school. I loved every minute of it, getting the
ponies in before I went to school. I have worked in retail and a charity, all in
management positions. My hobbies are varied; I love gardening and have an allotment. I
also do quite a lot of sewing.
During the last year I have found myself to be very forgetful, i.e. deciding what we
were going to have for our evening meal, and completely forgotten by lunchtime; going
into town shopping to get something specific, forgotten by the time I get there,
particularly if the list has been left at home! The wake-up call to the problem really
began when I found myself driving along a local road, not having a clue why I was there.
Also my husband was getting cross and would say, ‘you know we decided on dinner
this morning’; yes, we had, but I had completely forgotten. I have always been a person
that writes lists. I had to when I had a lot of staff to organise and needed rotas, so that
we all knew what was happening. I also keep a FiloFax and a list of what is happening
daily at home, but even these were getting muddled up.
Having decided something was wrong and I must do something about it, I first went
to my doctor who was very helpful. She sent me for blood tests galore (I felt like Tony
Hancock when I came out, no blood left). The results couldn’t really find much wrong.
She referred me to the Memory Assessment Service where I was sent for a scan and
more tests.

SUMMARY

Neuropsychology makes a difference to people’s lives at times of great vulnerability and

change, by helping with understanding what is happening to them, and by helping people
and their families adapt to a change in their situation which may be sudden (as with a
 WORKING IN NEUROPSYCHOLOGY 255

stroke) or more gradual (as with a dementia). Neuropsychology draws upon the knowledge
gained more generally from clinical psychology, coupled with neuroscience. This work
takes place in a range of different settings, from the very medical (e.g. supporting neuro-
surgery) to working with a patient in their home. The role may be either exclusively
assessment focused (e.g. in a diagnostic service, which may assess whether a person has
a dementia) or focused on working with the often devastating effects of having a
neurological condition (such as a brain injury caused by an accident), offering psychological
support around adjustment and cognitive rehabilitation. This chapter aims to describe
this role in more detail, highlighting some of the settings and work that a neuropsychologist
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might do, with examples illustrating the curious way in which our lives can be affected
by changes in our brains, and how neuropsychology can help when this happens.

INTRODUCTION

‘Neuropsychology’: The branch of psychology that deals with the relationship

between the nervous system, especially the brain, and cerebral or mental functions
such as language, memory, and perception.
(www.thefreedictionary.com)

Neuropsychology offers a fascinating insight into the amazing functions of the brain,
and indeed the distressing effects on people when aspects cease to work efficiently.
For example, the accountant who can no longer do a simple arithmetic task, the teacher
who has forgotten how to write her name, the woman who draws only the right side
of a house and says it’s complete, the man who is shown a picture of a scarecrow but
only sees the grass on which it stands, the previously law-abiding woman who now
parks in the middle of roundabouts. All of these examples are real and represent
significant changes from the person’s previous abilities. They present new and
frustrating challenges for the person and their loved ones and one of the jobs of a
neuropsychologist can be to support people in understanding and adjusting to these
issues. In many cases the cause of such difficulties may be obvious, for example, after
a stroke or after a head injury, but at other times the neuropsychologist may play an
important part in determining the diagnosis, alongside neuroimaging (brain scans) and
other investigations, for example, in a dementia. Thus the neuropsychologist may need
to offer support to an individual and their family at a very upsetting time. However,
this can also be an enormously rewarding and humbling aspect of the job.

Background to the field

When we look back at the origins of this specialty, neuropsychology is, relatively
speaking, one of the newer branches within psychology, although references pertaining
to discovery in the field date back to ancient Egypt (Finger, 2000). For many centuries
the brain was not seen as important and was often thrown away at autopsy when other
organs were kept.
Learning about the brain has ranged from the less credible theories (e.g. the study
of ‘phrenology’ (Franz Gall, 1758–1828) where lumps and bumps on the skull were
 256 ANGELA REASON ET AL.

Metal rod that changed a man’s personality

Phineas Gage was a young man injured in the mid-nineteenth century whilst
working on a railroad in Vermont. He was packing explosive powder with a
tamping iron when a spark from the iron ignited the powder and sent it
straight through his skull and brain. He survived the injury but his family and
colleagues reported subsequent dramatic changes in personality.

His contractors, who regarded him as the most efficient and capable
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foreman in their employ previous to his injury, considered the change in

FOCUS 15.1

his mind so marked that they could not give him his place again. He is
fitful, irreverent, indulging at times in the grossest profanity.
(Harlow, 1848)

This case was important in developing our understanding of the role of

behaviour and personality associated with the frontal lobes.

thought to represent people’s mental and moral faculties), to more robust findings such
as Pierre Paul Broca’s (1824–1880) theory of regions in the brain responsible for
expressive speech which still stand strong today.
This latter discovery came about from the study of a man who could only say one
word (‘Tan’). The learning that has been gained through real-life examples is perhaps
one of the most interesting areas and shows the powerful effect of damage to the brain
on functioning.

AREAS OF NEUROPSYCHOLOLOGICAL PRACTICE

A neuropsychologist’s role can be extremely varied and is certainly not confined to

being stuck in a room mechanically ‘testing’ someone. Even if assessment is a large
part of the role, every individual comes with a unique and fascinating narrative and
profile of functioning which makes the role both diverse and appealing.
It provides opportunity to work across a range of settings and with a variety of
patient groups. This may be in a specialist neurological service where the neuro-
psychologist may assist the neurosurgeons in monitoring functions such as speech
during a surgical procedure, or working alongside neurologists to clarify diagnosis or
areas affected by a neurological condition. For example, Gill, a 45-year-old nurse,
diagnosed with a type of brain tumour called an astrocytoma, was assessed by the
neuropsychologist to see what aspects of her brain functioning were affected and to
try to pinpoint more specifically in which areas of the brain the difficulties arose. A
specialist neurological service may be in a hospital where patients are either inpatients
or come in as outpatients, or it may be within the community, for example, a
community neuro-rehabilitation team which endeavours to support people in reaching
their own goals for recovery.
Another area for work may be within a mental health service. The neuro-
psychologist may be asked to investigate whether a patient’s difficulties are due to
 WORKING IN NEUROPSYCHOLOGY 257

psychological factors or due to a neurological condition. Many neuro-degenerative

conditions can present with mood/psychiatric factors early in the course of the
condition and may thus be misdiagnosed. Conversely, some psychiatric/psychological
conditions may initially be mistaken for neurological conditions (for example, non-
epileptic seizures). There may also be lifestyle factors that affect the brain which need
exploring and understanding. For example, Ben, a 19-year-old university student, had
previously shown promise at school and been an A-grade student. Following a period
of heavy illicit drug and alcohol use he was struggling with his course and had to drop
out. He could not concentrate or remember aspects of his course work. The neuro-
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psychologist offered an assessment to review whether there was significant cognitive

impairment and to consider what strategies may support him to return to further
education.
Neuropsychologists may also work privately, for example, providing expert opinions
during legal processes, such as if there appears to be impairment following a road traffic
accident, or on capacity issues, such as if a person has the mental capacity to make a
decision about their finances.
Table 15.1 highlights some of the types of clinical conditions one might come across
in different settings.
Thus you can see that the neuropsychologist needs a broad understanding of the
effects many different conditions can have on the brain and on behaviour.

TABLE 15.1 Types of problems with which neuropsychologists work

Category Examples of conditions
(not an exhaustive list)
Acquired brain injury Stroke, hypoxia, head injury
Progressive/degenerative Dementia, Parkinson’s disease, Huntington’s disease, Multiple
Sclerosis, Motor Neurone Disease
Medical Seizures, cardiovascular, liver disease, respiratory disorders
Neuro-oncology Brain tumours
Psychiatric Psychosis, Bipolar disorder
Toxic Alcohol-related brain damage, drug use, exposure to neurotoxins
Inflammatory Encephalitis, Meningitis
Neuro-developmental Learning disabilities, Autistic Spectrum disorders
Other Medically unexplained symptoms

Clinical psychology and clinical neuropsychology

FOCUS 15.2

Clinical psychologists have a basic introduction to neuropsychology through

their core training and may conduct cognitive assessments with a range of
client groups, including those in neurological settings.
Clinical neuropsychologists have undergone further specialist training in
clinical neuropsychology and thus have a more specialist role in this field.
 258 ANGELA REASON ET AL.

NEUROPSYCHOLOGY IN ACTION

Neuropsychology involves both assessment and contributing to rehabilitation. This

section outlines the various ways in which neuropsychological assessment may be used
to make a difference by answering particular questions about a person’s situation,
including what may be causing their difficulties, and whether they have the capacity
to make particular decisions. It then outlines the contribution that neuropsychologists
can make to helping people adapt to their changed situation following a neurological
event such as a brain injury.
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Neuropsychology and assessment

The image of a neuropsychologist conducting assessment probably conjures up one
of sitting in a bare room with a range of tests and a stopwatch. In many ways this
image is correct, as the neuropsychologist needs to ensure the test results are not affected
by other distractions, are based on standardised measures, and are a true reflection of
the person’s abilities. However, the work is far more engaging and intriguing than this
image portrays.
Formal tests are only one aspect of a neuropsychological assessment as we also need
to obtain a formal history of the presenting problems from the patient and ideally from
other people who know the patient well. As with clinical psychology more generally,
the patient’s story is crucial to understanding the problem.
Once the patient/relative has been able to provide a narrative of the issues,
assessment can take many forms. Most typically the neuropsychologist attempts to
‘measure’ aspects of brain functioning according to ‘cognitive domains’. Effectively
this is a little like visualising a world globe (the brain) and travelling around the different
continents (the lobes) and countries (more specific brain areas), seeing what works well
and what doesn’t (the domains). Domains include the following:

• Orientation
• Attention and concentration
• Memory
• Language
• Visual perception and visual spatial skills
• Executive function
• Speed of processing
• Praxis.

However, formal testing may not always be possible. Sometimes neuropsychologists

have to think on their feet and draw on different resources. For example, Graham, a
52-year-old engineer, was not able to complete the tests brought for their session due
to difficulties in understanding visual information. The neuropsychologist resorted
instead to rummaging in her bag and pulling out a variety of items, including a pen,
a mobile phone, a hair clip and some coins. They then looked at whether Graham
was able to identify and name the items and whether he could recognise the value of
the individual coins. This allowed for informal assessment of the domains of visual
perception and language in a format with which Graham could engage.
 WORKING IN NEUROPSYCHOLOGY 259

Equally, if a patient is not able to attend a clinic for assessment for any reason, the
neuropsychologist may need to conduct an assessment in other settings. This can be
challenging given that the reliability of testing is heavily dependent on the tests being
given in a structured and specific way. However, a neuropsychologist may need to
try to do the best possible in such a situation. This may mean administering a test on
a busy hospital ward, or in a patient’s home with the cat on their lap. One strange
assessment situation involved a patient constructing a makeshift testing table in their
studio out of an amp and a guitar box while seated on a drum-kit stool. It was
surprisingly sturdy!
We will now consider more specific ways in which neuropsychological assessment
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is used.

Assessment for diagnosis: what’s wrong?

In a diagnostic setting the work often feels like being a detective. The patient is referred
to the service with some unexplained symptoms and the team get to work in trying
to solve the riddle, using a variety of tests and investigations of which neuropsychology
is one part. Many conditions may be determined easily (e.g. presence of a brain tumour
visible on a scan), although assessment is still useful in finding out its effects on
cognition; but with rarer conditions the diagnostic process can be a real puzzle and
some conditions such as dementia still cannot be definitively confirmed until autopsy
(which is a little late!).
As we saw with Jan, blood tests didn’t reveal any problems and she was referred to
the Memory Service with the cause of her problems unknown. She had a brain scan
which was also inconclusive and so the neuropsychological assessment was an essential
component in trying to establish what was happening to her. Part of the work was
also in preparing her for what might be found (often referred to as pre-diagnostic
counselling).
In some cases testing will reveal problems immediately and the clinical picture will
be clear. However, in other cases the assessment may be diagnostically inconclusive
but it will be useful in profiling someone’s strengths and weaknesses at that time point
(a ‘baseline’) and allow for measurement of change over time (e.g. the assessment may
be repeated some months later to see whether decline or recovery has occurred).
Diagnostic work may be conducted in both inpatient or community settings, for
example, in an acute hospital, in a specialist neurological centre, or within community
services such as memory assessment teams, dementia services or mental health teams.
Examples of typical referral questions are as follows:

• ‘This lady appears to have some progressive cognitive impairment. Please could
you assess whether this lady may have an early stage dementia?’
• ‘Please assess this lady to help clarify whether her dementia is of Alzheimer’s type
or a vascular dementia.’

Assessment for profiling function: what works well and

what areas are damaged?
Neuropsychologists may still need to conduct assessments even when the diagnosis is
clear. The aim of this is to gain a clearer picture or profile of the damage to the brain
 260 ANGELA REASON ET AL.

affecting an individual’s behaviour and thinking. As we saw in the example of Gill,

the woman with an astrocytoma tumour, assessment may aim to clarify in which areas
of the brain the impairments are found.
Assessment is also very helpful in providing personalised information on an
individual’s abilities (strengths and difficulties) specifically to inform care plans or
rehabilitation programmes. For example, with the accountant who wishes to return
to work but is now unable to calculate simple arithmetic tasks, the assessment may
reveal that he can still perform the task under certain conditions. For example, he may
be able to do the work successfully when calculations are broken down into step-by-
step stages and when he has a pen and paper to write things down, as opposed to trying
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to do them in his head. Knowledge of these details may be the difference between
him returning to work or not.
An example of a typical referral question is as follows:

• ‘Please could you undertake a cognitive assessment of this 26-year-old man who
has sustained a head injury but also has had epilepsy since he was young, to help
understand what cognitive difficulties have been caused by his more recent head
injury?’

Assessment for capacity: is the person able to make an

informed decision?
When people have cognitive difficulties, questions about their ‘capacity’ are often
asked. In these situations, assessment attempts to discover whether an individual is
capable of making an informed decision on a specific matter and whether they fully
understand the related implications. The Mental Capacity Act (2005) is aimed at
supporting the rights of people who lack the capacity to make decisions for themselves.
Assessment for capacity is in relation to a specific query, for example, whether
someone has the capacity to make particular financial decisions or to decide where
they want to live. Assessment may include a comprehensive interview with the patient
and possibly the use of formal tests.
Neuropsychologists, among other health professionals, may be asked to comment
on capacity issues. The neuropsychologist may offer advice about how to support a
patient’s capacity to make a decision, such as provision of written information for
someone with memory difficulties.
Examples of typical referral questions are as follows:

• ‘Please assess to see if this lady has the capacity to make a decision about remaining
in her own home.’
• ‘Does this gentleman have the capacity to make an informed choice about
refusing his treatment?’

Assessment for formulation: what factors might explain

these difficulties?
Psychological and neurological factors may overlap, and unpicking which is which can
be tricky. In reality, people don’t fit neatly into the theoretical boxes we often read
about. Developing a formulation involves wearing your clinical psychology and your
 WORKING IN NEUROPSYCHOLOGY 261

neuropsychology ‘hat’ and a touch of intuition. The art of collating all the information
about a patient into a coherent understanding of their presenting difficulty is key. This
may involve reviewing a range of factors, for example:

• Your observations of the person.

• The person’s past and current situation and feelings.
• The person’s family context and other psychosocial factors.
• Knowledge of neurological disorders and how they present.
• Knowledge of psychiatric/psychological disorders or factors and how they present.
• Neuropsychological test results.
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• Other clinical information (e.g. brain scan results, medical history).

On consideration of these variables, one needs to then consider how they may interact
for a specific patient. Figure 15.1 attempts to illustrate these components. For example,
a patient who has been diagnosed with multiple sclerosis (MS) (biology) may be
experiencing anxiety about future deterioration (psychology) and now relates to her family
differently for fear of worrying them about her problems (social). She may be worrying
about her memory, and so it is necessary to understand how worry and the MS can
influence the efficiency of memory (mechanism), understand how it manifests (symptoms),
and also what goals she wants to achieve, for example, wanting to stay in work for as
long as possible (everyday functioning) which is currently not possible due to her
problems with forgetting to do things (limitation). A neuropsychologist’s job is to help
the patient understand this process, how each of these factors interacts and how they
can then use this information to make changes to their situation. For example,
introducing electronic memory aids on a smart phone may help reduce worry about
memory and enable the patient to carry on working.

Biological (organic) Psychological Social/context

(e.g. MS) (e.g. anxiety) (e.g. relationships)

Mechanism

Symptoms

Everyday functioning

Limitation

FIGURE 15.1 Example diagram of overall formulation

 262 ANGELA REASON ET AL.

Thus, a neuropsychologist’s role is like any clinical psychologist’s; that is, to be

flexible and thoughtful, always considering the patients within the context of their
everyday life and as a person; not just the brain damage.
Examples of typical referral questions are as follows:

• ‘Please assess this 46-year-old lady who experienced a traumatic brain injury last
year. She has subsequently separated from her partner and finds it difficult to
maintain a job.’
• ‘Please could you assess this 61-year-old gentleman who has recently lost his job?
He found the process of redundancy stressful and found it difficult to process orders
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for the company and complained of memory problems.’

In summary, the role of assessment in neuropsychology is wide and varied. Table 15.2
summarises the main purposes of assessment.

Neuropsychology and rehabilitation

We have so far described the varied role of assessment in neuropsychology, but another
key area in which neuropsychologists work is rehabilitation. This work occurs largely,
but not exclusively, with people who have suffered an acquired brain injury (ABI).
ABI refers to injury to the brain which has occurred after birth and is not accounted
for by neurodegenerative changes in the brain. Conditions may include traumatic brain
injury (e.g. resulting from a road traffic accident), stroke, anoxic injury (e.g. brain
starved of oxygen following near-drowning), and injury from infections affecting the
brain (e.g. from meningitis or encephalitis). There is also a growing interest in the use
of neuropsychological rehabilitation approaches with people with other types of
neurological conditions such as dementia (Clare, 2008).
Rehabilitation for patients is described as ‘a process aimed at enabling them to reach
and maintain their optimal, physical, sensory, intellectual, psychological and social
functional levels’ (World Health Organisation, www.who.int).
A neuropsychologist supporting a person with an acquired brain injury in
rehabilitation may take on a variety of roles across numerous settings, including hospital,
stroke or head injury units, in community rehabilitation teams, in regional neuroscience
centres or in specialist services such as neuro-rehabilitation centres, vocational services
or services for children with acquired brain injury and services for people in minimally
conscious/vegetative states.
Once again the neuropsychologist is usually part of a wider rehabilitation team,
all of whom play their part in the rehabilitation process. For example, John, 62,
suffered with language problems and weakness down one side of his body following
a stroke. The physiotherapist focused on helping him with his mobility, the speech
and language therapist assessed the degree and nature of his language difficulties and
practised techniques with him to help him speak again, the occupational therapist
helped him with aspects of daily living, for example, how to make an evening meal,
and the neuropsychologist assessed him and found problems with memory function,
and considered memory strategies that might be helpful to him.
The emphasis in neuropsychological rehabilitation over the years has developed from
an impairment-led focus to a more holistic approach which focuses on everyday skills
 WORKING IN NEUROPSYCHOLOGY 263

TABLE 15.2 Summary of main purposes of assessment in neuropsychology

Purpose of assessment Clinical example
To determine a baseline. This means To determine if someone with Down’s
establishing a person’s level of functioning syndrome may be developing a dementia.
in order to then compare results at a later
time point.
To determine whether a person has Assessing someone following a head injury.
cognitive difficulties and if so, to what
degree/severity.
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To determine change in ability, i.e. if Assessing someone with a diagnosis of

cognitive decline is present. mild cognitive impairment to see whether
they have progressed to a diagnosis of
dementia.
To contribute to a diagnosis. Testing someone and offering a view on
the cognitive profile to assist diagnosis
(e.g. does the person have dementia with
Lewy Bodies or dementia of Alzheimer’s
type?).
Establishing the impact or effects of a Testing someone’s language function during
specific treatment such as neurosurgery epilepsy surgery.
or radiotherapy.
To explore if a person’s cognitive difficulties Assessing to see whether someone’s
are organic (in the brain) or psychological memory problems may be related to
in origin. depression.
To determine effort levels in a patient. Exploring whether someone’s test
performance may be influenced by
conscious or unconscious lack of effort.
To influence a patient’s care plan, Testing to determine how to help a patient
cognitive intervention or rehabilitation adapt to difficulties through individual
programme. cognitive rehabilitation.
To validate a patient’s experience. Testing a patient who is experiencing
subjective change to their memory even if
other investigations are normal.
To assess for capacity-related issues. To determine whether a patient with
Huntington’s disease is able to manage their
own finances.

and roles relevant to the individual (Wilson, 2001). The use of goal setting is common
and allows intervention to be focused on what is important to the patient. For example,
Julie, 32, was a successful advertising consultant and mother of two, who developed
viral encephalitis. She made a fairly good recovery initially but was left with some
memory problems. Her family assumed her ‘goal’ for rehabilitation was to return to
the job she loved, but for Julie, her focus was to be able to develop reminders and
memory aids to enable her to take her daughters to and from school successfully.
In rehabilitation work, a neuropsychologist may advise on compensatory strategies,
engaging the person and family in understanding their difficulties following injury.
For example, a patient with memory difficulties may benefit from a rehabilitation
 264 ANGELA REASON ET AL.

programme focusing on learning to use systems to support their memory (e.g. smart
phones, calendars, diaries, etc.). In addition, the neuropsychologist may have more of
a therapeutically focused role, helping the person and their family to adjust to the
injury/illness, which in ABI, usually by its nature, happens suddenly. This is likely to
include adapting therapeutic interventions such as cognitive-behavioural therapy
(CBT) and systemic therapies to minimise the impact of cognitive difficulties, for
example, by providing written summaries, having short sessions if fatigue or
concentration is an issue, and working with family.
Other interventions may include working on reducing the impact of changes in
behaviour which are common following brain injury and which can impact upon an
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individual’s social participation and challenge others (Wilson et al., 2003). A functional
analysis of behaviour which helps understand the triggers or consequences of behaviour
can help formulate an understanding of the behaviour and guide intervention.
Examples of typical referral questions are as follows:

• ‘Please could you see this 70-year-old man who, since he has experienced a head
injury following a road traffic accident, is fearful of going out?’
• ‘Please could you assess this 65-year-old lady who has had a stroke as she is having
trouble finding her way around the rehabilitation unit?’

CASE STUDY

Background
Jason, a 40-year-old married man and father of two young children, worked full time
as a web designer and was the main earner in his family. His wife worked as a part-
time nursery assistant. They lived in a mortgaged property. In his spare time Jason
loved family life, especially taking his son to football at weekends. He enjoyed
running, having recently achieved a half-marathon, and having the odd game of pool
at his local pub on a Friday night. He was also a keen motorcyclist and often relied on
this means of transport to get him to work.

The accident
One wet Wednesday morning Jason was travelling to work on his motorbike when
he was hit by a car and thrown off his bike. He was knocked unconscious at the
scene. He was rushed to hospital and once stabilised was given a brain scan which
showed he had sustained a head injury, which had mainly affected the front part of
his brain (his frontal lobes). He had also broken his right leg. He remained in hospital
for the next three months.

After hospital
Once discharged, Jason was transferred to the Community Neuro-rehabilitation
Team who carried out an assessment of his rehabilitation needs.
 WORKING IN NEUROPSYCHOLOGY 265

Medically, Jason had made a good recovery but there appeared to be some
cognitive difficulties evident and his family reported some changes in his
personality, saying he appeared more irritable, unreliable and unmotivated. His wife
described him as ‘uncaring and disinterested’ in her and the children and said, ‘he
has become lazy – I need to prompt him to do something or he just sits there’. This
meant she had to pick up more duties at home. His children struggled to
understand the changes and were concerned about whether they had caused the
problem: ‘I was naughty yesterday and daddy got really cross with me. He never
used to so I must have been really naughty.’
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Following discussion with Jason and his family the neuropsychologist met with
him to conduct a neuropsychological assessment. Jason completed a series of
tests and the assessment was able to shed light on areas of brain functioning that
remained intact and functions that were now impaired compared to how he was
previously. In particular it showed that he struggled with thinking skills such as
planning, organisation, initiation and attention which are all functions typically
implicated with the frontal lobes, as well as having some memory problems. An
assessment of mood indicated he was moderately depressed.

Formulation
The assessment results concurred with the brain scan findings and helped the team
formulate how Jason’s accident had contributed to the changes reported. It was
clear from his wife’s description of Jason prior to the accident that he was hard-
working and enjoyed social interaction, so his current malaise and lack of motivation
was unlikely to be due to factors explained by his previous (often referred to as
‘pre-morbid’) personality. It is also known that the problems the family described
were typical features following injury to the frontal lobes. Thus – if we refer back to
our model in Figure 15.1 – this was a likely biological explanation. However, Jason
was also showing signs of depression. He had discussed with the
neuropsychologist how he was aware he ‘felt different’ now and got ‘more grumpy
with the kids’. He was also missing work (he had not been able to return to work as
yet) and felt ‘useless’. This was having a notable effect on his mood. Thus it was
possible that some of his apparent apathy and lack of motivation was due to
psychological factors (see Figure 15.1). Furthermore, the changes to the family’s
situation were also having a more systemic effect, for example, on their finances
and on his relationships which was further impacting upon his mood.

Intervention
The formulation enabled the neuropsychologist, along with the team, to consider a
care plan for Jason and his family. First, she felt that some psycho-education would
be helpful in supporting Jason and his family in their understanding of the
difficulties to help shift the explanation away from ‘laziness’ to understand the
 266 ANGELA REASON ET AL.

changes as a consequence of his brain injury. She believed this psycho-education

might also help so that the children could stop blaming themselves unnecessarily
for any difficulties.
Jason, the neuropsychologist and the team’s occupational therapist then worked
together on implementing some strategies to help increase his independence.
Jason’s personal goal was to get back to taking his son to football at the weekend
(hampered by problems of getting started with things – known as initiation). Jason
was previously keen on technology and used a smart phone, so assistive technology
aids were recommended. Jason set up reminder alerts which activated at 9 a.m. on
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Saturday mornings, and comprised a checklist of tasks he had to do in order to take

his son out (e.g. ‘book taxi’, ‘pack season ticket’, etc.). Over a few weeks this
increase in independence had a notable effect on his mood and improved his
relationship with his son.
In addition, the family were able to attend some family support sessions to help
them reflect on the changes, such as his wife having to return to full-time work to be
able to support them financially. His children drew pictures to help them express
their views of changes to their dad.
Jason was also invited to a men’s group which focused on adjustment to brain
injury. Jason was able to talk in this group about his frustrations at not working but
also about changes in his family relationships. Other members in the group said
they related to the problems he raised. They also helped him think about practical
solutions to some of his goals, based on their own experience of overcoming
problems associated with brain injury. For example, one man told Jason to ‘count
to ten when you see the red mist [anger]’ which helped Jason control his
irritability towards his children. This may appear a simple technique but, coming
from another member in the group who had experienced something similar, it
held a lot of power.

Outcome
Jason remained with the neuro-rehabilitation team for a few weeks. Over this period
he developed a greater understanding of his difficulties, helping him to reframe some
of the unhelpful ideas he had developed about himself. Although many of his
cognitive difficulties remained, he was able to find alternative ways around some of
these difficulties and this meant he did not have to feel so reliant on his wife, which
in turn gave him a greater sense of well-being. He remarked that he realised he had
actually been quite depressed, which had resulted in some of the irritability and lack
of motivation. The men’s group had been a great source of support to him and given
him a sense of shared experience.
His family also felt more tolerant of the changes once they understood them as
being a result of his injuries and began to adapt to a new and different way of family
life.
Jason was discharged from the neuro-rehabilitation team after some follow-up
visits. His longer term goal was to return to his job.
 WORKING IN NEUROPSYCHOLOGY 267

TEAM WORKING/INDIRECT WORK

The neuropsychologist rarely works alone and is usually part of a wider clinical team,
even if indirectly. The brain is complex; we still have a lot to learn, so pulling together
and offering assessment and intervention from a holistic multi-professional approach
is crucial. The effects of brain injury or neurological illness are far-reaching. The work
can be both humbling and emotional, but maintaining an appropriate sense of humour
is also important for all. Teams must work together not only to support the person
and their loved ones, but also each other.
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CRITICAL ISSUES

With a developing field such as neuroscience, ‘hot’ issues change and evolve all the
time. One issue to date for neuropsychology has been between the use of a ‘fixed
battery’ approach to assessment (common in North America), which involves
administering a large and set number of tasks covering a wide breadth of cognitive
domains (time-consuming but thorough), versus that of the ‘flexible battery’ or
‘hypothesis-led’ approach (common in the UK) which aims to test only specific areas
according to the hypothesis or referral question (time-efficient but may miss
something). There are ongoing debates about which is the preferred approach, with
arguments on both sides.
Another area is the utility of tests across different cultural groups. This includes
considering what ‘normative’ sample test data is based on and how transferable tests
are across cultures and when English is not a person’s first language.
Finally, one area that is likely to be pertinent for the next generation of neuro-
psychologists is the improvements made to neuroimaging in the future and what this
will mean for the future of the specialty – will neuropsychological testing become
redundant at some point and the focus move entirely to rehabilitation?

CONCLUSIONS

In conclusion, neuropsychology is a branch of clinical psychology that focuses more

specifically on the way the brain works, and how it affects cognition, emotion and
behaviour. It is diverse, fascinating, and at times challenging, both practically and
emotionally. However, it is also immensely rewarding. It allows you to help people
and their families at a really vulnerable time in their life which is an enormous privilege.

CONCLUSION TO JAN’S STORY

Eventually I was sent to see a psychologist and met a very helpful lady; she was
friendly, but explained everything in great detail as we went along. If she wasn’t sure I
had understood she would go through it all again before starting the test. I felt very
much at ease with her, which helped a great deal, as I had found it a very big step to
admit anything was wrong.
 268 ANGELA REASON ET AL.

I found the whole experience very rewarding, some of the tests more difficult than
others, but that just proves to me that I was right to be concerned.
I do try to put as many of the things the tests taught me into my everyday work as
possible. I think the whole procedure was an excellent wake-up call, and I would
recommend it to anyone with the same or similar problems.

KEY CONCEPTS AND TERMS

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• Neuropsychology • Domains • Capacity

• Psychometrics • Acquired brain injury • Pre-morbid
• Cognitive • Rehabilitation

LEARNING OUTCOMES

When you have completed this chapter you will have gained:

1 Foundation knowledge of the field of neuropsychology.

2 An awareness of the different types of work and different settings in which a
neuropsychologist might work.
3 A flavour of some of the conditions with which neuropsychologists work.
4 An introduction to what a neuropsychological assessment and intervention may
involve.

SAMPLE ESSAY TITLES

• How can neuropsychological testing help patients?

• Describe three areas in which a neuropsychologist might work, describing briefly
what they might be asked to do.
• Discuss the areas a typical neuropsychological assessment would cover and how it
may guide rehabilitation.

REFERENCES

Clare, L. (2008). Neuropsychological Rehabilitation and People with Dementia. Hove and New York:
Psychology Press.
Finger, S. (2000). Minds Behind the Brain: A history of the pioneers and their discoveries. New York:
Oxford University Press.
 WORKING IN NEUROPSYCHOLOGY 269

Harlow, J.M. (1848). Passage of an iron rod through the head. Boston Medical and Surgical Journal,
39, 389–393.
The Free Dictionary. Available online at www.thefreedictionary.com.
The Mental Capacity Act. Available online at www.direct.gov.uk.
Wilson, B.A. (2001). Towards a comprehensive model of cognitive rehabilitation.
Neuropsychological Rehabilitation, 12(2), 97–110.
Wilson, B.A., Herbert, C.M. and Shiel, A. (2003). Behavioural Approaches in Neuropsychological
Rehabilitation: Optimising rehabilitation procedures. Hove and New York: Psychology Press.
World Health Organisation. Available online at www.who.int.
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Current
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 16 Clinical psychology:
past, present, future
Adrian Whittington and Nick Lake
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SUMMARY

Clinical psychology is a relatively new profession, but it has become a popular career
choice with fierce competition for postgraduate training places. Interest in the profession
has grown quickly and there are a number of high-profile clinical psychologists both in
the media and portrayed as characters in television and film. The status of the profession
is strong and public awareness high.
Despite this, the profession of clinical psychology had humble beginnings. This chapter
will provide a brief history of the development of clinical psychology within the UK,
highlighting how clinical psychologists have moved from a role based largely on
psychometric testing and research in the 1950s, to their role as behavioural practitioners
in the 1960s and 1970s, to the 1980s where practitioners began to integrate a wide
variety of psychological perspectives and clinical models in practice and apply their
knowledge as trainers, consultants and leaders, as well as therapists. We will aim to
bring this history to life by describing a typical working day of a clinical psychologist
during each of these periods. We will look at the role of the clinical psychologist in the
current NHS, highlighting some of the challenges and new opportunities that the
profession faces. We will also project ourselves forward over the next ten years to look
at how we think the profession will need to adapt and develop to meet the new demands
of health care as the twenty-first century unfolds.

INTRODUCTION

The profession of clinical psychology has grown rapidly in the UK. From its origin
in research labs, and as psychological technicians, you will now find clinical
psychologists occupying senior leadership positions in health care, as well as having an
increasing influence in other sectors such as recruitment, consultancy and leadership
development. As a profession grounded in the clinical application of the science of
psychology, clinical psychology has the potential also to expand into many other fields
 274 ADRIAN WHITTINGTON AND NICK LAKE

in health and social care, including a greater role in physical health care and public
health agendas such as enhancing well-being in the general population (making people
and society happier and healthier).
In the early twenty-first century, the expansion of psychological therapy services
in the NHS, often now provided by other professionals who cost less to train and pay,
has placed clinical psychology at a new crossroads. For some this is perceived as a threat
to the role of clinical psychologists in the NHS. We regard it as an opportunity. The
ability to apply psychological knowledge, and the breadth and depth of the clinical
psychologist’s training, will always be important when dealing with the more com-
plex cases and more challenging contexts faced in clinical practice. However, clinical
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psychology also occupies a unique role in offering an applied science of the human
psyche, which is different to both psychiatric medicine and to a model or a series of
models of therapy. This is not only important in further developing our understanding
of how to work best with individuals through integrating separate fields of theoretical
and research development (e.g. attachment research with research on cognition),
but it should also enable us to develop a greater understanding of how to work with
psychological distress across communities, services and teams. We believe that pro-
viding psychological interventions that impact upon more than just the individual will
be increasingly important in health care, as the focus turns to developing more
psychologically healthy teams, communities and societies, not just more psychologically
healthy individuals.
As you will see, clinical psychology and clinical psychology training has adapted
rapidly over the past 60 years, flexing to the changing demands being faced and to the
new understandings and knowledge that the science of psychology has brought us.
However, we cannot stop adapting. We will argue that clinical psychology train-
ing needs to adapt further, offering depth in specific fields of practice to complement
the breadth of theory, practice and research skills development which it currently offers.
We also need to strengthen further the training in leadership, ensuring that clinical psy-
chologists can act as architects of more psychologically informed mental and physical
health care, as well as more psychologically healthy communities as a whole.

A BRIEF HISTORY OF CLINICAL PSYCHOLOGY IN THE UK

Psychometrics and research

Psychology as an academic field appeared around the turn of the twentieth century,
bringing together medics, philosophers and other academics. The Psychological
Society was founded in London in 1901, defining psychology as a distinct and scien-
tific discipline. Interest in the application of psychological science grew, particularly
in relation to stress and industrial production, the impact of combat in the First World
War, and in applications to education.
The birth of the profession of clinical psychology may be associated largely with
the launch of the new National Health Service in 1948. Psychology graduates
found a place in the new service, typically assisting psychiatrists with diagnoses
through psychometric testing. This position was upheld by one of the most influential
psychologists in the field at the time, Hans Eysenck, who wrote: ‘the psychiatrist is
 CLINICAL PSYCHOLOGY: PAST, PRESENT, FUTURE 275

responsible for carrying out therapy. The psychologist for diagnostic help and research
design, and the social worker for investigating social conditions in as far as they affect
the case’ (Eysenck, 1949, p.174). This was a very different emphasis from that appear-
ing in the United States, where clinical psychologists were embracing psychotherapy
(at this time in the form of psychoanalysis) as a core component of their role.
Eysenck positioned psychologists in the UK as scientist-practitioners who should
not be concerned with psychotherapy and should not let social need drive their
activities, but rather focus on advancing psychological knowledge through research.
Based largely on this approach, the first UK training course in clinical psychology was
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established in 1957 at the Maudsley Hospital, London. This course was highly influ-
ential, training many early leaders in the field.

Behaviourism and psychotherapy

From the 1950s, significant steps were taken towards the use of behavioural method-
ologies (see Chapter 2) based on the work of B.F. Skinner, Stanley Rachman and
others. These methods were applied to address psychiatric difficulties including anxiety
and phobias and to shape behaviour in institutional environments, including the
widespread long-stay mental hospitals of the time (Baum, 2005). These methodologies
were incorporated by clinical psychologists hungry to expand their roles and took root
as part of the curriculum in the growing number of clinical psychology training courses
across the UK. Clinical psychologists took up positions in a wider variety of services,
including leading roles in services for people with intellectual disabilities.
In 1976, Aaron Beck published Cognitive Therapy and the Emotional Disorders (Beck,
1976), launching what was to become a very influential approach to psychotherapy. Beck
was a psychiatrist and psychoanalyst who had begun to question some accepted
psychoanalytic principles after exposing them to testing. Cognitive therapy, in contrast
to psychoanalysis, was located firmly within a scientific paradigm, which made it attractive
for UK clinical psychologists to adopt. It built upon their existing behavioural traditions.

THE DAY OF A CLINICAL PSYCHOLOGIST IN 1960

James spends the morning doing assessments for Dr Willett on Ward 4 of a large
psychiatric hospital. He produces a brief assessment report on two of the patients
to show the current severity of schizophrenia, having administered psychometric
measures. Hopefully this will influence their care. James isn’t convinced that one of
the patients has any active symptoms of schizophrenia, but may simply be showing
behaviours that are the effects of being in hospital for several years. In the
afternoon, James continues his research into the effects of the token reward
system that has been introduced on Ward 2. The nurses have been using tokens to
reward patients for attending to their personal hygiene. Tokens buy cigarettes and
sweets at the end of the week. James has been collating records of the changes in
behaviour over the past three months to see whether there has been an increase in
frequency of bathing and teeth cleaning.
 276 ADRIAN WHITTINGTON AND NICK LAKE

As training numbers grew over this period, clinical psychologists diversified, also
taking on a role in applying other psychotherapies in NHS contexts, including family
therapy and psychodynamic therapy.

Redefinition and team working

In 1979 a Conservative government under Margaret Thatcher set out to exert greater
control over costs of the NHS, introducing a stronger role for health service manage-
ment. Reviews of the NHS workforce were undertaken to seek greater efficiencies.
Community care was replacing long-stay institutions as the primary means of delivering
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mental health care at this time. Community multi-disciplinary teams were established
which brought together different professional groups in the task of providing
community services. In this atmosphere of change and threat, the profession of clinical
psychology, represented by the British Psychological Society Division of Clinical
Psychology, sought an independent review of the role of the clinical psychologist. The
result was the 1989 Manpower Advisory Service (MAS) report (Management Advisory
Service, 1989). While never fully adopted, the recommendations of this report have
proved highly relevant. The MAS report identified three levels of psychological skills:

Level 1: Communication skills and basic counselling.

Level 2: Defined psychological intervention skills (e.g. anxiety management groups,
behaviour modification).
Level 3: Skills in the use of multiple psychological theories to develop individually
tailored and adapted interventions to address difficulties at individual and
organisational levels.

Of these, the report suggested that all mental health professionals should have level 1
skills, that many would have level 2 skills, but that clinical psychologists were unique
in their level 3 skills. The report recommended an expansion of clinical psychology
training to deploy more of these skills into the NHS.

THE DAY OF A CLINICAL PSYCHOLOGIST IN 1980

Julie starts her day by doing two detailed assessments, helping to prepare for the
closure of the mental handicap hospital. The psychiatrist would be making a
decision about the next group to move out into a community group home, and has
asked for Julie’s opinion, so they are going to meet to discuss this. She is not
looking forward to it – they have quite different views and the psychiatrist thinks
the most severely disabled will never be able to manage in the community. Julie
spends the afternoon on Dolphin ward, where the nurses have asked for help with
stopping a young client slapping himself. Julie plans to complete a functional
analysis of the behaviour and produce a new care plan. At the end of the day she
finds a few minutes to read about a relatively new therapy approach: cognitive
therapy. She is very interested in learning more and in exploring whether this might
be adaptable to her work context.
 CLINICAL PSYCHOLOGY: PAST, PRESENT, FUTURE 277

Expansion and improving access

Although the MAS report was not directly acted upon by the government, the growing
profession of clinical psychology continued to prove its worth in teams. Greater
evidence of the effectiveness of psychological therapies started to emerge in the 1980s
and the public expressed a demand for talking therapies to be provided on the NHS.
Expanded numbers of posts continued to be developed but through the 1990s it was
typical for a proportion of these posts to remain vacant for long periods owing to a
shortage of trained clinical psychologists to fill them. It was hard for training pro-
grammes to keep pace with the need for expansion owing to the limited capacity of
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supervisors for the desired numbers of trainees. The incoming Labour government in
1997 heralded a period of significantly increased health service spending and this
resulted in the continued expansion of clinical psychology training to meet workforce
demand. Total numbers of clinical psychologists grew from 2,500 in 1992 to 6,900 in
2010 (Pilgrim and Treacher, 1992; Centre for Workforce Intelligence, 2012).
The early twenty-first century saw the unprecedented expansion of psychological
therapies under the Improving Access to Psychological Therapies (IAPT) initiative.
Richard Layard, a health economist, successfully argued that if services were expanded
to treat depression and anxiety disorders with CBT, this investment would pay for
itself through savings to the exchequer because a portion of those successfully treated
would return to work and stop claiming welfare benefits (Centre for Economic
Performance, 2006). On the back of this argument, £170 million was invested over
three years in training and employing new therapists, representing a doubling of

THE DAY OF A CLINICAL PSYCHOLOGIST IN 2000

Sally arrives at work at her Community Mental Health Team where she is the only
psychologist in the team. She attends the multi-disciplinary team (MDT) referrals
meeting. She has a year-long waiting list and colleagues at the meeting tell her
they are frustrated about this because they want their patients to have better
access to therapy. In the team formulation meeting (which involved all staff,
including the psychiatrist) that follows the MDT meeting, Sally facilitates an
exploration of what was going on for one of the clients who was causing the team
the most difficulty. Sally draws upon systemic, psychodynamic and cognitive
knowledge and theory in helping the team develop a bio-psychosocial formulation
of what was going on for that client. This helped the team adjust their treatment
plan and agree how they might better manage the client’s self-harming behaviour.
In the afternoon, Sally visits one client at home, and then goes over to the central
Psychology Department where she sees another two clients for individual sessions
in her consulting room. Sally catches up briefly with her trainee clinical psychologist
who had a potentially difficult session to manage today (they had discussed the
details in supervision the day before). The session went well. Sally is also pleased
to hear that they are continuing to expand the local training course to train more
psychologists for the NHS.
 278 ADRIAN WHITTINGTON AND NICK LAKE

investment in psychological services. Some of these new therapists have been clinical
psychologists, but the majority have been drawn from other professional backgrounds,
including mental health nursing and counselling. Cognitive-behavioural Therapy has
been the core of this expansion, but other psychological therapies that appear in NICE
guidance have been incorporated in the later stages. The IAPT services have operated
a ‘stepped-care’ model, with additional staff trained specifically to deliver ‘low-
intensity’ guided self-help interventions based on CBT principles. While psychologists
have played a key role in leading the new psychological therapy services, these services
have represented a move away from clinical psychology as the most numerous
professional supplier of psychological health care to the NHS.
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THE PRESENT: CLINICAL PSYCHOLOGY AT A CROSSROADS

(AGAIN)

The psychological therapies revolution

The expansion in resources attached to talking therapies in the period since 2007, under
strong central control from the Department of Health in the early stages, has had a
dramatic impact on the landscape of psychological care:

• It has raised public awareness and coincided with increased public desire for CBT
and other talking therapies.
• It has introduced a greatly expanded workforce of psychological therapists who
are not clinical psychologists.
• It has led to increased attention and routine collection of data on the outcomes
of therapy.
• It has led to an increased focus on the delivery of specified individual treatments
that appear in NICE guidance for specific diagnoses.

Proponents of the IAPT programme highlight that over a million additional people
received psychological therapy in the first three years of the new services, addressing
the previous scandal of a lack of access to talking therapy that had shown benefit in
research trials. Others have critiqued the focus of the new services on individual,
diagnostically driven interventions, when much human distress is known to be
associated with social and economic factors. For clinical psychology, the new services
highlight that effective therapies, particularly in primary care service settings, can be
provided by staff who are cheaper to employ than most clinical psychologists.

Cost pressures
Cost pressures in the period since 2010 have added to concerns and in some areas there
have for the first time been programmes of redundancies and reorganisation, resulting
in reduced pay for some clinical psychologists. Overall, workforce data show little
change over this period in the numbers of clinical psychologists, but the expansion
has certainly come to an end for now. The cost pressures of this period are reminiscent
of the1980s and the MAS report findings may have renewed relevance.
 CLINICAL PSYCHOLOGY: PAST, PRESENT, FUTURE 279

Partnerships of care
Since 2010 health policy has focused on increased localism – with local clinical
commissioning groups, led by general practitioners, responsible for the majority of the
NHS budget and a reduced role for strategic regional and national bodies within the
NHS. At the same time, the service-user movement has taken on new momentum,
with the users of services finding a voice in the design and delivery of health care.
The result is an environment that favours locally focused delivery of psychological care
involving both smaller and larger organisations, including charities, service-user groups,
NHS Trusts and private companies. Larger statutory organisations are increasingly
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partnering with smaller third sector organisations, offering benefits to both parties.

Demographic changes
The population in the UK is ageing, with the projected numbers of people over 85
years in England due to rise from 1.1 million in 2009 to 2.6 million in 2032. This
change will see a rising need for health services, in particular for long-term physical
health conditions (e.g. diabetes, stroke or heart disease) and dementia. About 50 per
cent of all GP consultations and 70 per cent of hospital bed use are for long-term
conditions and the probability of mental health problems rises with the number of long-
term conditions that a person suffers from. Numbers of people with dementia are due
to double, from 700,000 in the UK in 2009, to 1.4 million in 2039. These changes
are likely to require a fundamental shift in how health and social care is provided, with
a need for more home-based care, a greater reliance on unpaid and family carers, and
the use of new technologies to enable access to support. (Ham et al., 2012).

FUTURE DIRECTIONS: AN INTEGRATED APPLIED SCIENCE

OF PSYCHOLOGY

As we move into an environment shaped by an expansion of psychological therapies,

cost pressures, new organisational arrangements and demographic changes, clinical
psychology faces both challenges and opportunities. Clinical psychologists will need
to demonstrate explicitly their value beyond providing a single model of therapy and
have the opportunity to be architects of psychological care across physical as well as
mental health services. We illustrate this section with brief case studies of clinical
psychologists taking hold of this opportunity and reflect upon the implications for
clinical psychology training.

Moving beyond a model of therapy

Providing therapies is likely to continue to be an important part of the role for clinical
psychologists. In practice, clinical psychologists are trusted as team members competent
to achieve good therapy results with the most complex cases, often integrating methods
and ideas from more than one model of therapy. However, they currently face two
challenges as providers of therapy. First, they risk being seen as expensive therapists who
are not guaranteed to have recognised levels of competence in ‘approved’ single modality
 280 ADRIAN WHITTINGTON AND NICK LAKE

therapies as defined by the national bodies offering accreditation in these therapies. This
can be addressed by individual practitioners and training programmes working to ensure
that defined standards of competence are met in specific therapies that they offer. Second,
while many hold that the integration of different therapy models is a core feature of
being a clinical psychologist and provides added benefit in therapy (Hollanders and
McLeod, 1999), research efforts have not been focused sufficiently in this area to fully
evaluate this claim. This sort of research into the flexible application of therapy models
with people with multiple and complex difficulties is bound to be challenging, but
requires further investment.
Clinical psychology can also offer much more in addition to providing psychological
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therapy. Psychology is a broad field of knowledge, and the application of psychology

in clinical practice offers myriad ways in which this changing field of knowledge may
be brought to bear on human distress (Gilbert, 2009). The application of broader
psychological science continues to be needed across numerous areas in the current
health and social care system. These applications include acting to:

• Understand and support communities.

• Help grow healthy organisations (including through leadership).
• Enable teams and networks to pursue psychological well-being.
• Recognise and work with the crucial role of families and attachment in creating
emotionally healthy individuals and emotionally healthy communities.
• Work therapeutically with individuals, groups and families whose emotional
difficulties do not fall easily into current diagnostic categories.
• Work with people with complex mental health difficulties who haven’t responded
to psychological therapy.
• Develop service initiatives to support the growing proportion of the population
affected by long-term physical and neurological conditions, and their carers.
• Design supervision and reflective practice systems to allow services to remain
compassionate when they are themselves under threat.
• Produce research and training to help others advance knowledge of, and capacity
to intervene in, all of the above.

To be true to the broader field of psychology, the profession now needs to reassert its
broader role. This is not to set itself up in opposition to the defined psychological
therapies. Many psychologists have been working for years to increase access to these
therapies. Yet, in addition to acting as therapists, clinical psychologists should be leading
on initiatives to address human distress from many different angles.

Integrating the biological, the psychological and the social

Divisions continue in the provision of mental health care, with biological, psychological
and social models upheld by different individuals within teams. Because of their broad
training, clinical psychologists are well placed to break down these barriers and to
promote an explicitly biopsychosocial model of mental health care.
There is also increasing awareness of the role of psychological factors in aspects of
health care traditionally delivered according to a biomedical model, including long-
term physical and neurological conditions (such as diabetes, heart disease, pulmonary
 CLINICAL PSYCHOLOGY: PAST, PRESENT, FUTURE 281

CASE STUDY: SARAH AND THE NEW CONSULTATION

SERVICE
Sarah is a newly qualified clinical psychologist who has just joined a community
learning disability team. The consultant psychologist in the area intends to redesign
their way of working to offer brief formal psychological consultation sessions to
people with intellectual disabilities, together with their family members, care staff
and professionals in the wider system of health and social care. Sarah contributes
to the design and delivery of the new consultation service by reviewing the relevant
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literature and research evidence. As a result, they define a five-stage consultation

model based on established family therapy practices and Edgar Schein’s work on
process consultation (Martin and Milton, 2005; Schein, 1999). The psychologists
start to work in pairs to elicit different perspectives on referred problems from all in
the system at an initial consultation meeting, then offer structured reflections on
the issues raised. They also collaborate with the system to design solutions. This
sort of work had not been formally evaluated in intellectual disability services
before. Sarah researches potential methods of measuring outcomes for the
consultations, and the team of clinical psychologists agree on a feedback process
and follow-up questionnaires so that they can evaluate the impact of the service.

disease, stroke, dementia and chronic pain). There are often good health economic
reasons to address physical health with a more integrated model of care, as psychological
factors play such an important role in how people manage long-term health conditions
and adjust to physical decline or loss. Put simply, psychologically effective health care
may reduce the need for some repeat consultations and expensive medical intervention.
With an ageing population and projections of massively increased demand on NHS
services, this economic argument may open up significant new roles for clinical
psychologists to implement psychological health care in what have traditionally been
physical health care settings.

Clinical psychologists as clinical leaders and the architects of

psychological care
Increasingly clinical psychologists are taking up leadership in teams and NHS
organisations. Some leadership positions occupied by clinical psychologists are formal
leadership posts leading the whole clinical team, or leading psychology in a team.
Clinical psychologists are also directors of NHS Trusts, taking up roles at board level
or leading on areas such as research, education, or across a large clinical field. For many,
however, leadership is not clearly defined within a specific job, but is still required
(for example, leading on specific service development or research projects). Clinical
psychologists are well placed to offer leadership, being a highly selected group trained
to postgraduate level, and with some training coverage of leadership and organisational
psychology. There is increasing recognition currently that clinical staff can offer
 282 ADRIAN WHITTINGTON AND NICK LAKE

CASE STUDY: JASON AND THE NEURO-BEHAVIOURAL

CLINIC
Jason is a clinical psychologist with five years’ experience since qualification
working in a pain management clinic with people with long-term health conditions.
There is a specialist neuro-behavioural assessment service locally which
assesses children and adults suspected of suffering with neuro-behavioural
conditions such as Tourette’s syndrome (characterised by involuntary tics and
vocal expression) and attention deficit and hyperactivity disorder (characterised
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by high levels of distractibility). Both conditions can lead to significant social and
occupational difficulty but there is currently no psychological input available
locally. Jason is invited to design a psychological intervention service to attach to
the clinic, including the main empirically supported treatments – Habit Reversal
Training for Tourette’s (Piacentini and Chang, 2006) and a specific form of CBT for
ADHD (Ramsay and Rostain, 2007). Jason designs a service plan based on group
and individual interventions, and the service wins a bid to the local commissioners
to pilot it. As a result Jason and a CBT therapist are employed to deliver the
service.

aspects of leadership that non-clinical managers may struggle to offer – implementing

a vision of health care in a manner that is directly informed by clinical practice. This
offers a great opportunity for clinical psychologists to become influential by taking up
formal and informal roles as leaders, and by doing so to advance the quality of psycho-
logical health care.
Clinical psychologists can legitimately see themselves as architects of psychological
care. The increased programme of building psychological therapy services in recent
years does not threaten the need for new psychological service architecture and design
but embeds its importance. As architects, clinical psychologists have always, and always
will, find themselves involved in new projects, implementing change and delivering
psychological aspects of care in new ways. By taking up roles of influence at all levels
of organisations they can continue to drive forward psychologically informed health
care to face the challenges ahead.

Implications for clinical psychology training

There are a number of implications of this analysis for the future of clinical psychology
training. Clinical psychologists are increasingly positioning themselves as leaders and
architects of psychological health care. The breadth of their training across different
theoretical and empirical aspects of psychology provides essential equipment to do this.
However, to lead in services that increasingly deliver specific defined interventions,
training must also equip clinical psychologists with the depth in these approaches, such
as CBT or systemic psychotherapy. This will enhance credibility and the potential to
shape future services.
 CLINICAL PSYCHOLOGY: PAST, PRESENT, FUTURE 283

CASE STUDY: JAMILA AND THE PATHWAY FOR

PSYCHOLOGICAL CARE FOR CHILDREN
AND FAMILIES
Jamila is a consultant clinical psychologist who is the psychology and psychological
therapies lead for a large children and young people’s mental health team covering
a population area of 100,000. Jamila is aware of a national push to increase the use
of evidence-based psychological therapies for children, under the children and
young people’s IAPT programme. She works with service managers to make a
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successful bid for some national monies to train three nurses and a social worker in
the team to deliver CBT for children. Aware of the evidence for multiple forms of
therapy for children, she also convenes a group including the team manager, a
senior family therapist, art therapist and child psychotherapist to design an
integrated psychological pathway of care so that children and families entering the
service receive a form of help targeted at their particular difficulties, based on the
NICE-based evidence and professional consensus. This pathway proves a success,
and outcome measures demonstrate that all the forms of therapy are proving
helpful to children in the service. As a result the pathway is adopted by other teams
in the locality.

The development of multiple entry routes to psychological therapy practice has also
highlighted the haphazard nature of current training pathways. Some clinical
psychologists train in a specific psychological therapy before undertaking their
doctorate, others afterwards, others not at all. Meanwhile 10,000 psychology students
are graduating each year, and often find it difficult to gain a foothold in any training
pathway to enable them to work in mental health. New attention to designing
integrated training pathways could help ensure that clinical psychologists arrive at the
completion of their doctorate training with in-depth training in one or more methods
of psychological intervention as well as a broad-based training and all of the benefits
that this brings. For example, new roles for psychology graduates within services, with
training attached, could ensure this. Finally, with clinical leadership emerging as an
important role for clinical psychologists, it will be important for this to feature as an
explicit and significant component of doctorate training, preparing clinical psychologists
to lead in multi-professional services earlier in their careers than has been the case in
the past.

CONCLUSION

The profession of clinical psychology in the UK has grown in a dramatic way in terms
of both numbers of practitioners, and in the range of work and activities they do, since
the 1950s. The influence of the profession has grown, and a qualification in clinical
psychology will open many doors in many fields. However, the profession will need
to continue to adapt and develop, as it has always done, to meet the ever-expanding
 284 ADRIAN WHITTINGTON AND NICK LAKE

THE DAY OF A CLINICAL PSYCHOLOGIST IN 2025?

Fahima splits her working week between her role as a private therapist and her role
as a leader of a new ‘Sussex Dementia Care Alliance’. She starts the day by
sending two video tweets from her home office, ensuring she follows the current
Royal College of Clinical Psychology’s guidance on the use of psychosocial media.
Fahima is reluctant to move to the open online visual forums that people are
constantly connected to through their Apple eye glasses and feels that Twitter,
although a largely obsolete medium, is still the best way of connecting to her
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followers. One of the tweets is for 2,000 community dementia care volunteers.
There are a couple of direct messages on her account from carers in crisis and she
takes time to respond to these.
After this she completes two Skype therapy sessions. She is pleased that both
clients have made good progress on their online outcome measures, which means
she is eligible for a small bonus payment this month from the clients’ NHS
insurance schemes.
In the afternoon, Fahima attends a leadership meeting for the Dementia Care
Alliance. Her co-leader is a local carer of someone with dementia, and the
partnership includes representatives from the local council, two charities and
Seaview Health, a private company providing all NHS-funded primary care mental
health services in the region. The partnership are using today’s meeting to look at
the outcome data assessing the ongoing programme of activities aimed at
enhancing the well-being of carers of people with dementia as assessed by online
data provided by these carers. They are also reviewing data evaluating the
improvements to emotional well-being being experienced by the dementia care
volunteers as a consequence of the voluntary work they are undertaking. Through a
strong government-driven public health campaign over the past five years, giving
back to your community in some formal way is now seen as important for everyone
in contributing to a ‘well’ society. However, dementia care is often seen as one of
the less attractive options available, and struggles to attract people’s interest.
Fahima and the other members of the alliance are working to challenge the stigma
that they believe may be contributing to this view, looking to demonstrate the
positive psychological impact (upon well-being and self-esteem) that caring for
people with dementia can have for these volunteers.
Fahima sees two more clients in the evening in the ‘emotional fitness’ section
of her local gym.

challenges and opportunities of psychological and physical health care in the twenty-
first century. We hope that this chapter has given you some sense of what these key
challenges and opportunities might be. For the aspiring clinical psychologist, the
increasing recognition of the benefits of developing more psychologically healthy
individuals, teams, organisations and communities means that there are good prospects
for an increasing range of interesting and innovative work that will require your skills.
 CLINICAL PSYCHOLOGY: PAST, PRESENT, FUTURE 285

KEY CONCEPTS AND TERMS

• Psychometrics • Improving access • Talking therapies

• Behaviourism to psychological • Clinical leadership
• Cognitive therapy therapies (IAPT)
• Workforce
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LEARNING OUTCOMES

When you have completed this chapter you should be able to:

1. Describe the history of clinical psychology in the UK.

2. Understand how the current context may influence the future role of clinical
psychology.
3. Understand ways in which clinical psychology could draw further upon core
psychological science and apply this to enhancing well-being.

SAMPLE ESSAY TITLES

• How has the role of the clinical psychologist changed since 1950, and what roles can
clinical psychologists expect to take up in the next ten years?
• What are the main similarities and differences in the roles of psychological therapist
and clinical psychologist?
• Why are clinical psychologists seemingly always re-inventing their role in the NHS?

REFERENCES

Baum, W.M. (2005). Understanding Behaviourism: Behaviour, culture and evolution. Malden, MA:
Blackwell.
Beck, A.T. (1976). Cognitive Therapy and the Emotional Disorders. New York: Meridian.
Centre for Economic Performance (2006). The Depression Report: A new deal for depression
and anxiety disorders. London School of Economics and Political Science. Available online
at http://cep.lse.ac.uk/textonly/research/mentalhealth/DEPRESSION_REPORT_
LAYARD2.pdf (accessed 23 November 2013).
Centre for Workforce Intelligence (2012). Workforce risks and opportunities: Clinical
psychologists, psychological therapists and related applied psychology divisions. Education
Commissioning Risks Summary. Available online at http://www.cfwi.org.uk/publications/
applied-psychologists-workforce-risks-and-opportunities-2013-education-commissioning-
risks-summary-from-2012/@@publication-detail (accessed 4 January 2014).
 286 ADRIAN WHITTINGTON AND NICK LAKE

Eysenck, H.J. (1949). Training in clinical psychology: An English point of view. American
Psychologist, 4, 173–176.
Gilbert, P. (2009). Moving beyond cognitive behavioural therapy. The Psychologist, 22(5),
400–403. Available online at http://www.thepsychologist.org.uk/archive/archive_home.
cfm?volumeID=22&editionID=175&ArticleID=1505 (accessed 23 November 2013).
Ham, C., Dixon, A. and Brooke, B. (2012). Transforming the Delivery of Health and Social Care:
The case for fundamental change. London: The Kings Fund. Available online at http://www.
kingsfund.org.uk/sites/files/kf/field/field_publication_file/transforming-the-delivery-of-
health-and-social-care-the-kings-fund-sep-2012.pdf (accessed 4 January 2014).
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Hollanders, H. and McLeod, J. (1999). Theoretical orientation and reported practice: A survey
of eclecticism among counsellors in Britain. British Journal of Guidance and Counselling, 27(3),
405–414.
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at http://www.mas.org.uk/uploads/articles/MAS%20Review%201989.pdf (accessed 23
November 2013).
Martin, E. and Milton, A. (2005). Working systemically with staff working in a residential home.
Context: The magazine for family therapy and systemic practice, Special Edition, Grey Matters:
Ageing in the Family, 77, 37–39.
Piacentini, J. and Chang, S. (2006). Behavioral treatments for tic suppression: Habit reversal
training. Advances in Neurology, 99, 227–233.
Pilgrim, D. and Treacher, A. (1992). Clinical Psychology Observed. London: Routledge.
Ramsay, R. and Rostain, A. (2007). Cognitive-behavioural Therapy for Adult ADHD: An integrative
psychosocial and medical approach. New York: Routledge.
Schein, E.H. (1999). Process Consultation Revisited: Building the helping relationship. Boston, MA:
Addison-Wesley.
 17 Moving forward into
clinical psychology
Clara Strauss and Mary John
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SUMMARY

The aim of this chapter is to help you consider how you may want to apply what you
have learned from your psychology degree in your future career. Clinical psychology can
offer an excellent career path to make a real difference to people’s lives using psychology
in practice, high levels of job satisfaction and a relatively good income in the health sector.
However, it is certainly not the right choice for everyone and there is a range of related
career options. In this chapter we overview a number of career choices for psychology
graduates in health and social care, then focus in detail on clinical psychology training.
We provide information and advice about what clinical psychology training involves, and
what you will need to do to secure a place. Overall this chapter can help you consider
whether or not this is the right career choice for you and, if it is, enable you to move
forward towards this goal.

INTRODUCTION

It is important to understand in detail what being a clinical psychologist involves as

part of your career decision making. Other parts of this book can help with this. Before
reading this chapter you will find it helpful to first read Chapters 1, 2 and 3. Chapter
1 provides you with an insight into the working life of a clinical psychologist and
Chapter 2 outlines the principles on which the profession of clinical psychology are
based and how these principles are applied in practice. Chapter 3 focuses on the
opportunities and challenges of working in multi-disciplinary teams, and includes an
overview of the roles of the different disciplines in the health and social care sector.
This chapter focuses on career choice and in particular training to become a clinical
psychologist. It provides information to help you decide whether or not this is the
right profession for you and, if so, what you will need to do to realise your aspiration.
For further information on the role of the clinical psychologist see Hall and Llewelyn
(2006) or Beinart et al. (2009).
 288 CLARA STRAUSS AND MARY JOHN

Completing an undergraduate or conversion degree in psychology provides a really

sound platform for a number of careers within the health and social care sector. The
degree offers you an opportunity to blend your approach to inquiry through both the
humanities and the sciences; the former through the provision of experiences to think
critically and articulate thoughts through essays and reports and the latter through
opportunities to develop hypotheses and then the consequential testing of these
hypotheses. Alongside these core skills the degree facilitates the process of acquiring
an understanding and knowledge of fundamental psychological processes and principles
from, for example, information processing, neuropsychology, cognition, memory,
developmental and social psychology perspectives to, at a more fine-tuned level, the
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developmental trajectory of the emergent self. In addition, the degree provides

opportunities to consider the application of these principles to all walks of life
including in health and societal contexts. Communication and critical thinking skills
are central to the degree with an emphasis on being able to understand the underlying
theories as well as their application to daily life with the appreciation of the impact of
cognitive biases on what is heard and digested and relayed.

I HAVE A PSYCHOLOGY DEGREE: HOW CAN I USE IT WITHIN

THE HEALTH AND SOCIAL CARE SECTOR?

There are a wide range of roles in health and social care that are opened up if you
have a degree in psychology, some of which are as follows:

• Clinical psychology
• Academic research and teaching
• Psychological therapy
• Nursing
• Occupational therapy
• Social work
• Medicine
• Management and finance
• Human resources.

The careers that psychology graduates choose to enter are highly varied, as highlighted
in the list above. The skills attained at undergraduate level are evident in the com-
petences of the front-line health and social care professions (e.g. psychotherapy,
nursing, occupational therapy, social work and medicine). They all require critical
analysis, the understanding and use of research as well as person-centred skills such as
those required to communicate effectively whether orally or in written form. Support
services, such as human resources within organisations, also use these skills to enable
and maintain the effective functioning of the wider organisation.
A career in applied psychology draws upon the entire undergraduate syllabus as this
is the foundation for the necessary postgraduate skills and competences. Within the
applied psychology career pathway the application and translation of psychological
theory into real-life predicaments for individuals and their social networks are central
 MOVING FORWARD INTO CLINICAL PSYCHOLOGY 289

to the process of understanding the emotional lives of individuals across the lifespan
and offering helpful interventions. Within postgraduate courses there is emphasis on
developing advanced research skills so that the evidence base can be contributed to
and so that evidence-based practice can be adopted and implemented effectively.

WHICH OF THESE CAREERS SHOULD I CHOOSE?

Making the choice of career may seem daunting as the thought of spending an entire
life time engaged in one form of activity can be inconceivable. This can be more
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overwhelming if leaving university with little experience of the working environment.

To help in this decision-making process it is advisable to try to gain as much
information as you can from a variety of sources so that you have an unbiased and
clear picture of what will be required and what the longer term opportunities are within
that sector. Books can help (e.g. McDonald and Das, 2008), but taking the initiative
in seeking out people who are doing the job is a really helpful way of gaining a more
grounded understanding of what a day in the life of an individual undertaking this
career may be like. This direct contact will enable you to grasp the core aspects of the
job that you will enjoy, as well as the less wonderful but nevertheless important aspects
which you may find difficult, boring, demanding or emotionally distressing. Building
on this with visits to career advisers and shadowing someone adds to the richness of
your understanding. At some universities the psychology degree is offered with an
additional placement year, typically taken in the third year. This can provide an in-
depth opportunity to explore your chosen field as well as specific aspects of it, for
example, working with adults with psychosis or with young people. Securing a
placement in the health care sector while being supervised by a member of the
discipline is invaluable and for many undergraduates this experience clarifies that the
current career is worth pursuing, while for others it helpfully determines that there is
a need to focus attention elsewhere. You may wish to consult the NHS careers website
(www.nhscareers.nhs.uk) which provides a link to all the NHS jobs and training
courses, and the Clinical Psychology Clearing House (www.leeds.ac.uk/chpccp)
which provides information on all the clinical psychology training programmes in
the UK.

AM I SURE THAT I WANT TO BE A CLINICAL PSYCHOLOGIST?

The allure of becoming a clinical psychologist can organise individuals’ lives for a
number of years. The path of obtaining at least a 2.1 degree, experience of working
within an applied psychology context to obtain skills and knowledge followed by the
application process can take between five and eight years to achieve. The competition
is strong with about six candidates for every clinical psychology training place across
the country and some courses having fiercer competition. To commence on this
pathway when there are other interesting career opportunities for people with a psy-
chology degree needs careful thought, as this time is precious in terms of personal
and professional development. To this end it is worth examining one’s motivations
 290 CLARA STRAUSS AND MARY JOHN

for wanting to become a clinical psychologist. Does the career sit easily with your
personal values and goals, and do the NHS and other health care providers also rest
easily with these values? There can be a misperception about what the job entails and
a lack of regard for the mental and physical robustness needed to attend to the
emotional distress of others. There is a real expectation that trainees and qualified
practitioners need to be able to multi-task, switching activities quickly, and being able
to apply knowledge laterally and creatively. For many this level of creativity is part of
the draw; for others it is daunting.
When considering this career there is a need to self-reflect and consider objectively
one’s personal strengths, learning needs and, importantly, limitations. Given the
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demands of the profession and the use of ‘self’ in the therapeutic endeavour, personal
emotional well-being needs particular consideration. This does not mean that someone
who has experienced a mental health problem should not join the profession. In fact,
this can be an important source of values and insight. However, we all need to be
committed to understanding ourselves, what triggers exist for personal distress and how
we can effectively manage in an environment that may elicit strong and difficult feelings
in ourselves. Without this self-knowledge, training can become very challenging. In
particular, the training experience can be deskilling at first, as previous ways of thinking
are challenged and new skills have to be acquired. The emphasis on being evaluated
by supervisors and others may be particularly challenging to some individuals who do
not feel sure about their own identity, and it is not unusual for trainees to experience
anxieties or low mood at times. Some choose to undertake personal therapy or other
self-development activities before or during training to help with these issues.
A further issue to consider is that of timing. When applying to undertake a
challenging course it is worth considering whether this is the right time. Are family
and friends supportive and will they be able to help you when life challenges present?
Is there an appreciation of what the course entails regarding the time commitments?
Finally, choosing the right course; the programmes across the country provide many
similar experiences but they also have some unique differences. To this end it is worth
really exploring which programme offers the optimal experiences in terms of your
specific learning needs and also holds a philosophy that you can appreciate and want
to uphold. The programme websites as well as the Clearing House Handbook and the
Alternative Handbook are all valuable sources of information.
There is no appropriate set of motivations for training as a clinical psychologist but
there are some that can be less helpful, for example, pursuing a career to try to resolve
one’s own or other family members’ ongoing emotional difficulties. In terms of
reflecting, it may be helpful to consider what you want from the role. Most individuals
who enter the profession do so at least partly for altruistic reasons, to try to make a
difference in the lives of others. However, this altruism needs to be moderated by
ensuring that helping is undertaken in collaboration, rather than being ‘done to’ or
‘done for’ the person being helped. For some, the rewards will be experienced through
seeing clients directly or supervising others, while for others a clinical academic career
provides the vehicle to effect change, either through the development of novel
research, translating this research into action, or training others in the application of
these techniques and processes.
 MOVING FORWARD INTO CLINICAL PSYCHOLOGY 291

I DO WANT TO BE A CLINICAL PSYCHOLOGIST: WHAT DO I

NEED TO DO NOW?

Clinical psychology training courses

The Clearing House for Postgraduate Training in Clinical Psychology, based at the
University of Leeds, administers applications for clinical psychology training in the UK
(www.leeds.ac.uk/chpccp). There are currently 30 clinical psychology training courses
in the UK, with courses spread fairly evenly across the country. In 2012 there were
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3,875 application forms for 586 places, meaning that approximately 15 per cent of
applicants were offered a place on a course.
Courses are three-year, full-time postgraduate doctoral programmes. They are
accredited by the Health and Care and Professions Council (HCPC) and by the British
Psychological Society (BPS). This means that while courses differ from each other in
terms of emphasis, there are common elements across all courses. Requirements are
that trainees undertake clinical practice placements in a range of settings (typically
working-age adult mental health, child and adolescent mental health, learning disability
services and older people’s mental health services), and there is often the opportunity
also to undertake a specialist clinical placement. Each placement lasts six months to a
year and is linked to a qualified clinical psychologist who provides weekly supervision
and often joint or observed practice.
Training is divided between placement, teaching and study time, with approximately
50 per cent of time spent on placement, with the other 50 per cent split between
teaching and study. Most courses will organise this through having two teaching or
study days and two to three placement days each week. Some courses, particularly those
in rural areas, provide teaching blocks with full-time placements in between these
blocks.
Teaching will cover a range of psychological theories, models and related practice
approaches. All courses will teach at least two psychological therapy approaches (one
of which must be cognitive-behavioural therapy (CBT)) with different courses
emphasising different approaches. Clinical psychologists are often involved in offering
a range of contributions to teams in addition to psychological therapy once they have
qualified, and teaching on courses reflects this. Teaching is likely to be offered on
supervision and consultation as well as on leadership, with clinical psychologists being
prepared to take on leadership positions in the NHS and other health settings. As this
is a doctoral-level programme, courses will provide teaching to equip trainees with
the necessary knowledge and skills to undertake research.
Assignments will include written case reports, service evaluation projects and a major
research project. As this is a doctoral training programme the assignments are expected
to be of doctoral (Ph.D.) standard with the major research project to make a novel,
theoretically important contribution to the clinical literature.
Courses based in large cities may offer placements within a small geographical area,
whereas courses in more rural areas are likely to offer placements across a wide area.
This may involve travelling for an hour or more each day to and from placement, and
this is worth considering before applying.
 292 CLARA STRAUSS AND MARY JOHN

Funding
At the time of writing, the NHS pays the tuition fees for clinical psychology training
and provides a salary for trainees. However, this arrangement has periodically come
under review and it is not certain that this will continue in its current form in the
years to come. The Clearing House website provides up-to-date information on
funding arrangements.

Entry requirements
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Graduate Basis for Chartership and academic qualifications

Courses require entrants to have an undergraduate psychology degree that has BPS
Graduate Basis for Chartership (GBC), meaning sufficient coverage of a psychology
curriculum and meeting defined standards of teaching. Many, but not all, UK
undergraduate psychology degrees confer GBC and so it is worth checking that your
undergraduate degree is eligible for GBC. If not it may be necessary to undertake a
further degree that does confer GBC.
Almost all courses will require an undergraduate psychology degree grade at a 2.1
or first. Some courses will consider a 2.2 but usually only with subsequent academic
qualifications such as a Master’s degree. In addition to having a 2.1 or first, many
successful applicants have Master’s degree qualifications and some also have Ph.D.s.

Relevant clinical experience

Courses also require entrants to have gained relevant experience in working in the
kinds of settings in which clinical psychologists work. This may involve working in
NHS settings, social services organisations or in the voluntary sector. Positions may
be voluntary or paid and may include psychology assistant or research assistant posts,
or a range of other relevant posts such as nursing assistant, support worker, mental
health practitioner or clinical associate in applied psychology. Some courses prefer
applicants to have held psychology assistant or research assistant posts, while other
courses welcome applicants with a broader range of relevant experience. What is
important is that the relevant experience positions have provided an opportunity to
apply psychological theories and models in practice, and it can be particularly helpful
to have had some supervision from a clinical psychologist. Work experience in the
NHS is not required by most courses but knowledge of the NHS and of the latest
NHS structures and policies is expected.
There are a number of ways of finding relevant clinical experience. The NHS will
advertise posts for research assistants, psychology assistants, support workers and other
relevant posts through their jobs website (www.jobs.nhs.uk), and research assistant posts
will be advertised through the university jobs site (www.jobs.ac.uk). You can sign up
for email alerts on both of these sites for jobs that may be of interest. Posts are also
advertised on the BPS job website (www.bps.org.uk/jobs/jobs) and it is worth
contacting NHS Trusts, charities, voluntary sector organisations and private providers
of health care directly for job opportunities. Although it is not a financial option for
everyone, some people gain voluntary experience, for example, through volunteer
internships. For further advice on gaining relevant experience see Knight (2002).
 MOVING FORWARD INTO CLINICAL PSYCHOLOGY 293

Courses vary in the amount of relevant experience needed before applying and it
is important to consult websites from individual courses first. Some will require several
months of relevant experience while others will require several years.
Research skills and experience
Research skills and experience are also required. Many successful applicants have
postgraduate research qualifications such as Master’s degrees or Ph.D.s, and many have
held research assistant posts. Having at least one peer-reviewed publication can be an
advantage as this can be one way of demonstrating research skills and experience (see
Hall, 2012).
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Personal qualities
In addition to the entry requirements outlined above, courses will also be looking for
certain personal qualities. Clinical psychology is a profession that involves working with
people who may be experiencing a great deal of distress or who may be vulnerable,
and so personal values are important. As well as applying psychological theory in clinical
practice clinical psychologists are also expected to be able to reflect thoughtfully upon
their own experiences and backgrounds and will be encouraged through supervision
to develop a greater self-awareness. Clinical psychologists are just the same as everyone
else and can experience high levels of distress in response to the work or in response
to events in their own lives. Clinical psychologists need to have a degree of resilience
and to be able to manage difficulties and seek appropriate support for themselves. For
further ideas on developing reflective capacity, see Thompson and Thompson (2008).
Equal opportunities and clinical psychology training
The clinical psychology training community is committed to continuing to improve
the diversity of the profession and welcomes applicants from a broad range of back-
grounds. Diversity is important because a helping profession such as clinical psychology
should aim to reflect all the members of the society that it serves.
At the time of writing, approximately 85 per cent of applicants and successful
candidates are women (Clearing House for Postgraduate Courses in Clinical
Psychology [CHPCCP], 2013). The majority of applicants are in their twenties,
although applications are received from people in their thirties and forties, and they
are no less likely to be successful than younger candidates (CHPCCP, 2013). In 2012
(the latest year for which figures are available), 10 per cent of candidates were from
black and minority ethnic (BME) backgrounds and 5 per cent described their sexual
orientation as gay, lesbian or bisexual (CHPCCP, 2013).
The profession therefore could be doing better to reflect the communities that it
serves. It seems that the challenge lies in A level (Guardian News and Media Limited,
2013) and university (Trapp et al., 2011) choices made whilst at school, rather than a
bias in the selection process for postgraduate training. For instance, the fact that the
vast majority of successful applicants are women reflects the fact that the vast majority
of applicants are women, which in turn reflects the fact that most undergraduate
psychology students are women (Trapp et al., 2011). In response to this, many courses
are proactively encouraging more men to choose psychology at undergraduate level
and to then apply for clinical psychology training. Many training courses also
proactively seek BME applicants and host pre-application selection events targeted at
 294 CLARA STRAUSS AND MARY JOHN

ROUTES TO TRAINING: YASMIN

I graduated from Loughborough University in 2006 with a first in B.Sc. Psychology.
After graduation, I gained a place on a graduate scheme in a FTSE 30 company.
As a graduate manager, I led and managed a range of projects in various parts of
the organisation. I loved working with teams and the fast pace of my job but also
felt that my work was not particularly interesting or meaningful, and I began to feel
that there was something missing in what I was doing. So I wondered if I could
apply my personal and professional skills to something more satisfying.
I attended a talk about the PsychD programme at the University of Surrey.
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I previously thought a clinical psychologist was just a therapist but I realised at the
talk that the role entailed so much more, which was attractive to me. I also realised
that as well as my personal skills, my business skills would be an advantage rather
than a hindrance, given that leadership was a key competence of a clinical
psychologist.
I gained just under four years of relevant clinical experience before I got a place
on training. I think I applied for over 100+ NHS posts to begin with and did not
get a single interview, so I started applying for roles outside the NHS. Eventually,
I managed to get a psychology assistant post with the Prison Service. I then
managed to get a foot in the door in the NHS, volunteering as an assistant
psychologist for one day a week around support worker shifts. Once I was in the
NHS, I started getting interviews for paid assistant psychologist posts and did two
assistant psychologist posts before getting a place on training, one in a forensic
setting and another in Child and Adolescent Mental Health Services.
I secured a place on clinical training on my third application. I saw my first
application as a way to become familiar with the application process and learn from
the experience. To my surprise, I got an interview and although it did not turn into a
place, the feedback was invaluable and it spurred me on.
I think my two assistant psychologist roles were crucial to gaining a place on
training due mainly to access to the network of support and contacts. As well as
developing my clinical skills in these roles, I had the opportunity to see successful
applications, discuss my application with psychologists and have a mock interview.
On my second application I managed to get two interviews, one of which turned
into a reserve offer. I remember feeling very disheartened and upset about not
getting a place, especially after all the preparation and anxiety of going through the
process. However, I applied once more the following year. I got three interviews
and accepted a place.
Getting a place on clinical training felt amazing. I think I was floating for about a
month! I felt so relieved that the effort was all worth it and I was actually going to
be a clinical psychologist.
Starting training felt like a continuation of my journey to qualify as a clinical
psychologist. Looking back, I feel grateful for all of my work experiences prior to
 MOVING FORWARD INTO CLINICAL PSYCHOLOGY 295

starting training as I feel they prepared me for some of the challenges of being a
trainee. Clinical training is demanding and the workload is high. I sometimes feel
out of my depth, particularly with academic assignments, since it has been seven
years since I graduated with my Bachelor’s degree. However, it is also incredibly
rewarding and satisfying, and there is plenty of support from the course team as
well as 27 other people going through it with you.
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CASE HISTORY ROUTES TO TRAINING: CHRIS

Between 2002 and 2005, I completed my B.Sc. in Psychology (Hons.) and Human
Biology at the University of Plymouth and achieved an upper 2.1. In 2008 I started a
part-time M.Sc. in Developmental Psychopathology at Reading University and
finished in the summer of 2010 with a credit, gaining the Graduate Basis for
Chartership with the BPS. I began clinical training in 2010.
After finishing my first degree, I took on three jobs. I worked as a care assistant
in a residential home for older adults diagnosed with dementia. My role here was to
provide care for their physical and psychological needs. Meeting their psychological
needs included life story and reminiscence work. At the same time, I completed
training with the Samaritans and worked voluntarily as a Samaritans listener.
Towards the end of my first degree I also applied for a volunteer assistant
psychology job in a primary care setting, which would now most probably be
called an Improving Access to Psychological Therapies (IAPT) service. One day a
week I was involved in supporting adults with depression and anxiety to make
use of computerised CBT and guided self-help. In late 2006, after nearly 18 months
of juggling jobs, I decided to shift my focus back towards working with
adolescents, which had always been of clinical interest to me. Between late 2006
and 2009 I was employed by Connexions as a youth worker, offering support and
guidance to young people who had been excluded from secondary school for
emotional and behavioural difficulties. In 2009, I transferred to a local CAMHS
service and provided this support to young people with more severe mental health
difficulties.
When I applied in 2009 I did not seriously think that I would secure a place on
clinical training the first time. I treated the application as a practice. I applied to the
University of Surrey, Royal Holloway, UCL and the Institute of Psychiatry. I
remember expecting to be asked to take the entrance exam as I met the criteria.
Although the exam was tough in the sense of time management, I was in the
process of writing up my M.Sc. dissertation, so research design and statistics were
at the forefront of my thinking, which certainly helped. Although I was certainly
nervous on the day of the interview, I do also remember a feeling of being put at
ease. The situational interview was what I expected. I was, however, surprised by
 296 CLARA STRAUSS AND MARY JOHN

the personal suitability interview, which felt more like a chat. I have always been a
very reflective person and having this ability felt like a very important part of
selection.
As I come to the end of training, I have definitely changed in terms of my
thinking and practice. The key components that the training at Surrey has provided
me with are the emphasis on reflection and the importance of working within the
scientist-practitioner model. I do not think I was expecting such a commitment to
developing research skills, but in order to make sense of research in terms of
clinical practice, this is vital. I have enjoyed and felt challenged in the process of
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developing my therapeutic skills and have been pleased with opportunities to make
use of training and supervision to develop other competences of being a clinical
psychologist such as consultation and leadership.

BME undergraduate psychology students. All courses welcome applications from all
candidates, irrespective of background.

Work permits and English language proficiency

Applicants must be allowed to work in the UK and, if relevant, to have a UK work
permit. Applicants who do not speak English as a first language will be required to
have an International English Language Testing System (IELTS) certificate at level 7
or above.

I THINK I AM READY TO APPLY FOR CLINICAL PSYCHOLOGY

TRAINING: WHAT DO I NEED TO DO?

1 The first thing to do is to look at the Clearing House website (www.leeds.ac.uk/

chpccp) to check that you meet all the currently relevant criteria, as these may
have changed since this book was published.
2 Decide which four courses you would like to apply to. Not all courses are the
same and so you will want to carefully consider which courses are right for you.
The Clearing House website provides links to all the individual course websites
where you can find out more information about each course, its specific entry
requirements, and its ethos, content and structure. The Alternative Handbook is
produced by the Division of Clinical Psychology and presents the views and
experiences of trainees on each of the 30 courses. You can download the latest
copy of the handbook from the British Psychological Society online shop by
searching for ‘Alternative Handbook’ at http://shop.bps.org.uk/publications.
html.
3 Applications are made online through the Clearing House website. The site opens
for new applications in September each year with the deadline for applying at the
beginning of December, but make sure that you check the deadline, as these can
change from year to year.
 MOVING FORWARD INTO CLINICAL PSYCHOLOGY 297

4 The application form will ask you to provide details of your qualifications and
relevant experience as well as to provide a personal statement. A guideline
document for completing the application form is available on the Clearing House
website. You will also be asked to name two referees, one to provide an academic
reference and the other to provide a relevant experience reference.
5 Some courses have a written or screening test and these occur between the
beginning of February and mid-March each year.
6 All courses interview potential trainees with interviews occurring between mid-
March and mid-May. Most applicants will not be offered an interview owing to
the large number of applications. Courses apply robust criteria to screen applicants
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for interview based on the application form and, where relevant, based on
performance on the written or screening test.
7 Following interview, courses will offer places to successful candidates and offer a
selection of other candidates a place on their reserve list. Most courses interview
many more candidates than they have available places, so it is likely that the
majority of interview candidates will not be offered a place.
8 Candidates are required to accept an offered place by the beginning of June and
any remaining places will be offered to candidates on the reserve list.
9 Courses start in September or October.

It is important to remember that only 15 per cent of applicants in 2012 were offered
a place on a course. The majority of applicants have a strong academic record, plenty
of relevant experience and good references. This means that not being successful in
obtaining a place does not necessarily mean that you will not make an excellent clinical
psychologist one day and many people apply several times before being successful.

WHAT HAPPENS IF I AM NOT SUCCESSFUL OR IF I

HAVE CHANGED MY MIND ABOUT BEING A CLINICAL
PSYCHOLOGIST?

As outlined earlier, there are many routes to working in the health and social care
sector. Clinical psychology involves applying psychological theories to real-life,
everyday situations, often when people are feeling distressed or vulnerable, and using
these theories in practice to help people move forward in their lives. However, clinical
psychologists are increasingly moving away from spending most of their time providing
direct therapeutic support and towards training and supervising others to provide
therapy, and towards taking on leadership roles in the health care and other sectors
(See Skinner and Toogood, 2010).
For those interested in a career as a psychological therapist there are a number of
routes and organisations whose role is to support this: the British Association of
Behavioural and Cognitive Psychotherapists (BABCP) can direct you if you wish to
become a cognitive-behavioural therapist (www.babcp.com), the United Kingdom
Council for Psychotherapy if you want to train in another form of psychotherapy
(UKCP; www.psychotherapy.org.uk), and the British Association for Counselling
Psychotherapists (BACP; www.bacp.co.uk) will direct you if you wish to become a
counsellor.
 298 CLARA STRAUSS AND MARY JOHN

If research particularly appeals to you then perhaps a career in a university setting

would be of interest. Following an undergraduate degree many people undertake a
Masters degree and then a Ph.D. before moving on to post-doctoral positions and then
on to a lectureship (See Phillips and Pugh, 2010). Ph.D. positions are often advertised
on the www.jobs.ac.uk website where you can sign up for email alerts, and individual
universities will often advertise Ph.D. opportunities on their websites.
Many people with an undergraduate psychology degree go on to train as nurses,
including as mental health nurses (see www.nhscareers.nhs.uk). This profession opens
up plenty of opportunities to work with people experiencing mental health difficulties
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and to gain further training, for example, as a cognitive-behavioural therapist (see

www.babcp.com).

FINAL THOUGHTS

This chapter has provided a detailed overview of what is entailed when training as a
clinical psychologist and the processes involved when applying for training. This
chapter has provided you with some important questions to consider about your future
career and whether or not clinical psychology is the right choice for you. Whatever
you decide, we wish you well.

KEY CONCEPTS AND TERMS

• Clinical psychology • Supervision and • Self-reflection

• Training consultation • Leadership
• Careers • Research • Support networks
• Psychotherapy • Resilience

LEARNING OUTCOMES

When you have completed this chapter you should be able to:

1. Consider the range of career options open to graduate psychologists in health

and social care.
2. Consider the right career direction for you.
3. Understand ways of gaining relevant experience for a career in clinical
psychology.
4. Navigate the system for applying for postgraduate training in clinical psychology
in the UK.
5. Cope better with whatever happens!
 MOVING FORWARD INTO CLINICAL PSYCHOLOGY 299

REFERENCES AND FURTHER READING

Careers information
NHS careers website: www.nhscareers.nhs.uk.
Clearing House for Postgraduate Courses in Clinical Psychology: www.leeds.ac.uk/chpccp.
Division of Clinical Psychology (BPS): dcp.bps.org.uk.
British Association of Behavioural and Cognitive Psychotherapists: www.babcp.com.
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United Kingdom Council for Psychotherapy: www.psychotherapy.org.uk.

British Association for Counselling Psychotherapists: www.bacp.co.uk.

Job advertisements
NHS jobs: www.jobs.nhs.uk.
University-based jobs: www.jobs.ac.uk.
British Psychological Society jobs website: www.bps.org.uk/jobs/jobs.

Equal opportunities in clinical psychology

Clearing House for Postgraduate Courses in Clinical Psychology (2013). Equal Opportunities
Numbers: 2012 Entry. Retrieved from: http://www.leeds.ac.uk/chpccp/BasicEqualopps
2012.html.
Guardian News and Media Limited (2013). A Level Results 2012: Breakdown by subject, gender
and region. Retrieved from: http://www.theguardian.com/news/datablog/2012/aug/16/a-
level-results-data-gender-region-subject#data.
Trapp, A., Banister, P., Ellis, J., Latto, R., Miell, D. and Upton, D. (2011). The Future of
Undergraduate Psychology in the United Kingdom. York: Higher Education Academy
Psychology Network.

Books
Beinart, H., Kennedy, P. and Llewelyn, S. (2009). Clinical Psychology in Practice. Chichester:
BPS Blackwell.
Hall, G.M. (ed.) (2012). How to Write a Paper. Chichester: Wiley Blackwell.
Hall, J. and Llewelyn, S. (eds) (2006). What is Clinical Psychology? Oxford: Oxford University
Press.
Knight, A. (2002). How to Become a Clinical Psychologist: Getting a foot in the door. Hove: Brunner-
Routledge.
McDonald, M. and Das, S. (2008). What to do with your Psychology Degree. Maidenhead: Open
University Press.
Phillips, E.M. and Pugh, D.S. (2010). How to Get a PhD: A handbook for students and their
supervisors (5th edn). Maidenhead: Open University Press.
 300 CLARA STRAUSS AND MARY JOHN

Skinner, P. and Toogood, R. (2010). Clinical Psychology Leadership Development Framework.

Leicester: Division of Clinical Psychology.
Thompson, S. and Thompson, N. (2008). The Critically Reflective Practitioner. Basingstoke:
Palgrave Macmillan.
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 Index

Note: Page numbers in bold are for figures, those in italics are for tables.
ABC model, and voice hearing experiences antipsychotic medication 136, 144, 243
140–1 anxiety disorders 112–29; aetiology 116–17;
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abuse 132; childhood 136, 156, 186; affective responses 113–14; agoraphobia
dementia 249; and PTSD 184, 186 21, 28–9, 114, 115; behavioural responses
acceptance 139, 144, 206 114, 124; behavioural theories 117;
acceptance and commitment therapy (ACT) biological factors 116; case study 120–5;
144, 224, 230 children and young people 61, 65, 81,
acquired brain injury (ABI) 262–4 82; co-morbidity and 96, 114; cognitive
Adaptive Behaviour Assessment System-II distortions 113, 119, 124; cognitive
(ABAS-II) 208 theories 117, 118; dementia sufferers and
adaptive functioning, domains of 200 carers 238, 243; diagnosis 114;
Adaptive Information Processing (AIP) 187, environmental factors 116–17;
189 epidemiology 114–16; generalised anxiety
addictions models, and eating disorders 178 disorder (GAD) 21, 65, 115, 116; and
adjustment, to physical health problems intellectual disabilities 201; interventions
220 for 21 (cognitive-behavioural therapy
administrative staff 41 (CBT) 65, 81, 115, 118–20, 126, 223;
adolescents see children and young people exposure therapy 118, 124; eye
adoption studies: depression 97; psychosis movement desensitisation and
135 reprocessing (EMDR) 21, 120; low-
aetiology: anxiety disorders 116–17; and high-intensity treatments 125–6);
borderline personality disorder (BPD) NICE recommended treatments 21;
156–7; childhood mental health obsessive compulsive disorder (OCD)
conditions 62–3; dementia 240–2; 21, 83, 113, 115, 116, 118; panic
depression 97–8; eating disorders 171–2; disorder 21, 113, 115, 116, 118–19;
intellectual disabilities 203–4; physical and physical health problems 218;
health problems and psychological distress physiological responses 114; post-
222–3; post-traumatic stress disorder traumatic stress disorder see post-traumatic
(PTSD) 185, 186; psychosis 134–6 stress disorder; prevalence 114, 116;
affect, and anxiety disorders 113–14 psychological factors 117; self-help
ageing population 248, 279, 281 materials 126; social phobia 21, 116;
agoraphobia 21, 28–9, 114, 115 specific phobias 115, 116, 118; team
Ainsworth, M.D.S. 161 working 125; trans-diagnostic
alcohol misuse see substance misuse treatments 126
Alternative Handbook 290, 296 anxiety equation 118
Alwin, N. 154, 156 applied behaviour analysis (ABA) 205
Alzheimer’s disease 207, 237 approved mental health professionals
Alzheimer’s Society 237, 239, 243 (AMHPs) 40
anorexia nervosa (AN) 21, 66–7, 82, 168, assessment 5, 8; and neuropsychology see
172, 177; case study 174–7; co-morbidity under neuropsychology; see also individual
170; diagnosis 169; epidemiology 171 case studies
 302 INDEX

attachment relationships 79, 152, 188; and disabilities 203; and post-traumatic stress
borderline personality disorder (BPD) disorder (PTSD) 186; and psychosis 134,
156–7 135
attachment theory 47, 63, 98, 156 biomedical model 280–1
attention-deficit hyperactivity disorder bipolar affective disorder 133
(ADHD) 61, 65–6, 82, 282 bipolar disorder 21, 82–3, 96, 134, 222
audit 16–17 Blum, N. 156
autism 200, 201 body mass index (BMI) 174
autistic spectrum disorder (ASD) 170 Boon, S. 192
avoidance behaviour 29; cognitive avoidance borderline personality disorder (BPD) 153,
122, 124; post-traumatic stress disorder 154–64; aetiology 156–7; and attachment
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(PTSD) 184, 186 relationships 156–7; and bio-psychosocial

model 156–7, 163; biological factors 156;
Bandura, A. 117 case study 158–62; diagnosis 162–3; and
Banerjee, S. 243 eating disorders 170; environmental
Bateman, A.W. 156, 158 factors 156; medication 158; NICE
Beck, A. 100, 102, 103, 113, 117, 118, 275 recommended treatments for 21; pathway
behaviour: and borderline personality model of treatment 157, 158, 163;
disorder (BPD) 155; dementia sufferers psychological difficulties that may occur
238; see also avoidance behaviour in 155; psychological interventions for 21,
behaviour therapy 9, 10, 26, 27–9; 157–8; self-management approaches 159;
behavioural activation 28, 40, 99, 100; team working 162
behavioural couples therapy 21, 99, 100; Bowlby, J. 63, 156
dialectical behaviour therapy (DBT) 21; brain development, and interpersonal
positive behaviour support 204–5; see also relationships 79
cognitive-behavioural therapy brain structure/function: bilateral stimulation
behavioural experiments 30, 106, 107, 119, 188, 189; and depression 97–8; and
228–9 psychosis 135; and PTSD 186; see also
behavioural responses to anxiety 114, 124 neuropsychology
behavioural theories: and anxiety disorders Brewin, C.R. 191
117; of depression 98 brief dynamic interpersonal therapy 30
behaviourism 275–6 British Association of Behavioural and
beliefs: delusional 131–2, 133, 138, 145; Cognitive Psychotherapists (BABCP)
health/illness 220, 222; reflection on 297
12–13; unhelpful 29; see also core British Association for Counselling
beliefs Psychotherapists (BACP) 297
bereavement 95 British Psychiatric Morbidity Survey
bilateral stimulation of brain 188, 189 114–15
binge eating disorder (BED) 168, 169, 173 British Psychological Society (BPS) 46, 192,
bio-psychosocial model 38, 43, 44, 217, 241, 291; Division of Clinical Psychology
280–1; and borderline personality (DCP) 42, 43, 276; Graduate Basis for
disorder (BPD) 156–7, 163; and dementia Chartership (GBC) requirements 292
240–2; of depression 97, 98; and Broca, P.P. 256
intellectual disabilities 203; and physical bulimia nervosa (BN) 21, 67, 82, 168, 172;
health problems and psychological distress diagnosis 170; epidemiology 171;
222; and psychosis 136 psychological interventions for 173
biological factors: and anxiety disorders 116; burn-out 192–3
and borderline personality disorder (BPD) Burns, D.D. 119
156; and childhood mental health
conditions 62; and depression 97–8; and cancer care 231
eating disorders 171; and intellectual capacity issues 178, 201, 257, 260
 INDEX 303

career choice(s): clinical psychology as classical conditioning 27, 28, 117

287–8, 289–90; motivations 289–90; for Clearing House Handbook 290
psychology graduates 288–9, 297–8 Clearing House for Postgraduate Training in
caregivers 59, 63; dementia 239, 243, 249 Clinical Psychology 289, 291, 296
Carr, A. 81, 82 client, as a term 4
case series 20 client groups 17
case studies: anorexia nervosa (AN) 174–7; clinical directors 40
anxiety disorders 120–5; borderline clinical experience, gaining 292–3
personality disorder (BPD) 158–62; clinical health psychology 217–32
childhood depression 67–71; dementia clinical leadership 46–7, 281–2, 283
244–7; depression 102–7, 109; intellectual clinical psychologists: communication skills
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disabilities 206–11; neuropsychology 10, 276; continuing professional

264–6; physical health problems 224–31; development 13; example week 4–5, 6–7;
psychosis 139–43; PTSD 188–91; personal qualities 293; relationship skills
systemic family therapy 83–6; team 8; research and service evaluation 16–17;
working 48–51 resilience 47, 293; role within
cerebral palsy 201 multidisciplinary teams 39–40, 45–7
challenging behaviour 204 (clinical leadership 46–7, 281–2; staff
childhood abuse 136, 156, 186, 192 support 47–8; team formulation 45–6);
children and young people 57–75, 283; self-reflection 290, 293; supervision 12,
aetiology of emotional/behavioural 13, 15–16, 280, 291, 292, 293; support
difficulties 62–3; anxiety disorders 61, 65, networks 293; teaching and training role
81, 82; attention-deficit hyperactivity 16; workforce numbers 277, 278; see also
disorder (ADHD) 61, 65–6, 82; bipolar consultant clinical psychologists
disorder 82; Common Assessment clinical psychology: art and science 19–36;
Framework 72; communication and as career choice 287–8, 289–90; cost
creativity in working with 67; conduct pressures 278; historical background
disorders 61, 65, 81, 82; consent for 273–8; training see training
psychological treatment 64; depression co-morbidity: and anxiety disorders 114; and
61, 66, 81, 82, 96; depression case study depression 96, 114; Down’s syndrome;
67–71; diagnostic labelling of 62; eating dementia 207; and eating disorders 170;
disorders 61, 66–7, 82; and family physical health problems 218–19, 221–2
therapy, effectiveness of 82–3; looked- cognitive analytic therapy (CAT) 66, 173,
after 62; multi-agency working 71–2; 224
normal development 58, 59; obsessive cognitive avoidance 122, 124
compulsive disorder (OCD) 83; person- cognitive distortions 113, 119, 124
centred recovery or social recovery 72; cognitive domains 258, 267
prevalence of common psychiatric cognitive functioning 200, 218
diagnoses 61; self-harm 61–2, 82; sources Cognitive Model of PTSD 187
of psychological help for 63–4; substance cognitive processing therapy 187
misuse 82; use of theory and evidence in cognitive rehabilitation 242
psychological practice with 64–7; young cognitive restructuring 187
offenders 62 cognitive stimulation therapy 242
Children and Young people’s Increasing cognitive stress-coping model 222
Access to Psychological Therapies (CYP cognitive theories: anxiety disorders 117,
IAPT) 81 118; depression 98, 102, 103
Children and Young People’s Mental Health cognitive therapy 29, 103, 108, 275;
Services (CYPMHS) 64 intellectual disabilities 205–6; see also
choice of therapy 23 cognitive-analytic therapy (CAT);
Christensen, A. 100 cognitive-behavioural therapy; person-
Clark, D.M. 113, 187 based cognitive therapy (PBCT)
 304 INDEX

cognitive-analytic therapy (CAT) 21 counselling 99, 101, 276, 297; pre-diagnostic

cognitive-behavioural theory 117 259
cognitive-behavioural therapy for bulimia counselling psychologists 39–40
nervosa (CBT-BN) 67 couples therapy 78, 81; behavioural 21, 99,
cognitive-behavioural therapy (CBT) 9, 10, 100
21, 26, 29–30, 264, 278; anxiety disorders critical-practitioner model 20
65, 81, 115, 118–20, 126, 223; attention culturally sensitive practice 86
deficit hyperactivity disorder (ADHD) 66, culture: and neuropsychological assessment
282; dementia sufferers and carers 243; 267; and physical health problems 221
depression 20, 21, 66, 81, 95, 99–100, cycle of change model 173
101, 108, 223; eating disorders 66, 67,
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173; intellectual disabilities 205–6; delusional beliefs 131–2, 133, 138, 145
physical health problems 223, 224, 228; dementia 236–53, 279, 284; abuse and poor
training in 297; trauma-focused 186, 187 practice 249; aetiology 240–2; and ageing
cognitive-behavioural therapy enhanced population 248, 279; antipsychotic
(CBT-E) 173 medication 243; behavioural distress
cognitive-behavioural therapy for psychosis occurring with 238; bio-psychosocial
(CBTp) 136, 138, 144, 145 model 240–2; caregivers 239, 243, 249;
collaborative practice, in family therapy case study 244–7; diagnosis 237–8, 249;
86–7 and Down’s syndrome co-morbidity 207;
combat stress 186 epidemiology 239; formulation 243–4,
Common Assessment Framework 72 244–6, 247–8; interventions for 242–4
communication: dementia and difficulties (cognitive rehabilitation 242; cognitive
with 238; with young people 67 stimulation therapy 242; cognitive-
communication skills, clinical psychologists behavioural therapy 243; family therapy
10, 15, 276 243; life history work 242–3;
community care 276 reminiscence therapy 242, 243); living
community mental health nurses (CMHNs) well with 239; neuropsychological
40 assessment 238; NICE recommended
community psychology 26, 95 treatments for 242; person-centred care
competence 279–80 244; prevalence 239, 248; psychological
complex PTSD 184, 185, 188 difficulties that may occur in 238–9;
concentration difficulties: depression 96; psychological needs of people with
post-traumatic stress disorder (PTSD) 241–2; public awareness 249; quality of
184; psychosis 132 care 249; risk factors 240; team working
conditioning: classical 27, 28, 117; operant 247–8
27, 28, 117 dementia care mapping (DCM) 244
conduct disorders, children and young dementia-friendly communities 249
people 61, 65, 81, 82 demographic changes 279
consent for psychological treatment, children depression 93–111; aetiology 97–8; and anti-
and young people 64 depressant medication 20; and anxiety co-
consultant clinical psychologists 13–17; morbidity 96, 114; behavioural theories
communication skills 15; consultation of 98; bio-psychosocial model of 97, 98;
role 16; example week 14; formulation biological theories 97–8; case study
skills 13–14; leadership role 13, 15; 102–7, 109; in children and young people
supervision 15–16 61, 66, 67–9, 81, 82, 96; cognitive theory
consultation 16, 281, 291, 296 of 98, 102, 103; dementia sufferers and
continuing professional development 13 carers 238, 243; diagnosis 96; and eating
coping 220, 227 disorders 168–9, 170; epidemiology 96;
Coping Cat programme 65 and intellectual disabilities 201;
core beliefs 102–3; negative 103, 106 interventions for (behavioural activation
 INDEX 305

99, 100; behavioural couples therapy 21, 61, 66–7, 82; co-morbidity 170; diagnosis
99, 100; cognitive-behavioural therapy 169–71, 177; and early intervention
(CBT) 20, 21, 66, 81, 95, 99–100, 101, concept 173; environmental factors 171;
108, 223; counselling 99, 101; family epidemiology 171; interventions for 21,
therapy 66, 82, 224; interpersonal therapy 66–7, 82, 172–4 (cognitive analytic
(IPT) 21, 66, 99, 100; mindfulness-based therapy (CAT) 173; cognitive-
cognitive therapy (MBCT) 21, 99, 108; behavioural therapy (CBT) 66, 67, 173;
short-term psychodynamic therapy 21, family therapy 66–7, 82, 173–4, 177;
99, 101); nature of 94–6; NICE interpersonal therapy (IPT) 173); nature
recommended treatments for 21, 66, 82, of 168–9; NICE recommended
99, 101; and physical health problems treatments for 21, 66, 82, 172; recovery
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218, 221–2, 223; protective factors 98; from 172; risk management 169; severe
psychodynamic models of 98; and enduring (SEEDs) 178; team working
psychological models of 98; and psychosis 177; trans-diagnostic model 177; see also
132, 133; relapse 108; risk factors for 96; anorexia nervosa; binge eating disorder;
self-help interventions 100, 101; social bulimia nervosa; obesity
and environmental factors 96, 98; effectiveness trials 20
stepped-care approach to management of Ehlers, A. 187
101; systemic theories of 98; team Emerson, E. 205–6
working 107 emotional instability, borderline personality
diabetes 82, 83, 170, 221, 224 disorder (BPD) 155
diagnosis 25, 38, 41–2; anxiety disorders 114; emotional reasoning 119, 135
children and young people 62; dementia emotionally unstable personality disorder
237–8, 249; depression 96; eating (EUPD) 170
disorders 169–71, 177; and family therapy empirically-supported treatments (ESTs) 21,
77; intellectual disabilities 200; and 22–3
neuropsychology 259; personality employment interventions, psychosis 136
disorders 153–4, 162–3; physical health Enabling Parents Enabling Communities
and psychiatric diagnosis 231–2; post- project 81
traumatic stress disorder (PTSD) 184–5; encopresis (soiling) 82
psychosis 133 enuresis 82
Diagnostic and Statistical Manual of Mental environmental factors: and anxiety disorders
Disorders see DSM 116–17; and borderline personality
dialectical behaviour therapy (DBT) 21 disorder (BPD) 156; and depression 98;
dissociation, PTSD 184, 185, 192 and eating disorders 171; and intellectual
dopamine 135 disabilities 204; and psychosis 134, 136
Down’s syndrome 201, 203; and dementia epidemiology: anxiety disorders 114–16;
co-morbidity 207 dementia 239; depression 96; eating
drug misuse see substance misuse disorders 171; intellectual disabilities 202;
Druss, B. 222 personality disorders 154; physical health
DSM-IV 153, 231 problems and psychological distress
DSM-V 42, 95, 114, 133, 153, 169, 177; 221–2; post-traumatic stress disorder
dementia 237; intellectual disabilities 200; (PTSD) 185–6; psychosis 134
physical health and psychiatric diagnosis epilepsy 201
231; PTSD 184–5, 193 Eriksen, E. 59, 60
evaluation: of interventions 11–12; service
early intervention 173 16–17
early life experiences 30–1, 121, 134, 152 evidence base 26; limitations in interpreting
eating disorders 167–81; and addictions 22–4
models 178; aetiology 1712; biological evidence-based practice 20, 23–4
factors 171; children and young people existential issues 221
 306 INDEX

experimental research 20 and depression 97; and eating disorders

expert practitioner model 86–7 171; and intellectual disabilities 203; and
exposure therapy 28, 118, 124; prolonged psychosis 135
187; PTSD 187 Glasgow Anxiety Scale for people with an
eye movement desensitisation and intellectual disability (GAS-intellectual
reprocessing (EMDR) 21, 120, 186, disabilities) 208
187–8, 189–90; Resource Installation graded exposure 40
approach 189 Graduate Basis for Chartership (GBC)
Eysenck, H. 274–5 requirements 292
grandiose delusions 132
false memories 192 group work 10, 65, 81, 100
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families: barriers to seeking mental health Gull, W. 171

services 80; community interventions for
80–1; culturally sensitive practice with 86; Habit Reversal Training for Tourette’s 282
life-cycle transition points 80 hallucinations 131, 133
Family and Friends Support Skills Health and Care Professions Council
Workshops 177 (HCPC) 291
family interventions/therapy 21, 32–3; health visitors 63–4
anxiety disorders 82; collaborative health/illness beliefs 220, 222
practice in 86–7; conduct disorders 65, Henggeler, S.W. 81
81, 82; dementia 243; depression 66, 82, Herman, J.L. 184
224; eating disorders 66–7, 82, 173–4, Holahan, C.J. 220
177; physical health problems 223–4; hot thoughts 105
psychosis 136, 138–9, 144; reflective hyper-arousal, PTSD 115, 183
practice in 86–7; somatic and hypersomnia 96
developmental difficulties 82; see also hypothalamic-pituitary-adrenal axis (HPA)
systemic family therapy 223
family studies 97 hypothetical worries 124
fight–flight response 30, 114, 118, 186
flashbacks 183, 184 ICD-10 42, 114, 153
‘Floatback’ technique 190 ICD-11 185, 193
Folkman, S. 222 illness model 25
Fonagy, P. 156, 158 immune system 219, 223
formulation 9, 13–14, 24, 38, 42–3, 64; Improving Access to Psychological Therapies
dementia 243–4, 247–8; and (IAPT) programme 101, 277, 278, 283
neuropsychology 260–2; psychosis 136, Improving Health and Lives 202
137; team 45–6; see also individual case indirect working 101; anxiety disorders case
studies study 125; dementia case study 247–8;
Freeman, D. 145 depression case study 107; eating
freeze response 186 disorders case study 177; intellectual
functional family therapy 81 disabilities case study 210–11;
neuropsychology 267; physical health
Gage, P. 256 problems case study 230–1
Gall, F. 255 inequality, social/wealth 95, 136
gate-control theory of pain 222, 228 infancy 61, 82
gender issues, and physical health problems information processing: adaptive 187;
221 psychosis 135, 138
generalised anxiety disorder (GAD) 21, 65, insomnia 96, 132, 219
115, 116, 121, 123 integrative approach 9, 10, 25, 33, 279, 280
genetics: and anxiety disorders 116; and intellectual disabilities 4, 199–215, 275;
childhood mental health difficulties 62; aetiology 203–4; and bio-psychosocial
 INDEX 307

model 203; biological factors 203; case localism, in health policy 279
study 206–11; diagnosis 200; ecological London Bombings (2005), PTSD case study
framework 202; environmental factors 190–1
204; epidemiology 202; interventions for long-term conditions (LTCs) 221–2, 279
204–6 (positive behaviour support 204–5; loss, and psychosis 132
talking therapies 204, 205–6); and IQ low mood: children and young people 59;
tests 8, 204; psychological difficulties that and depression 94, 95, 98, 103; and eating
may occur 201–2; and sexuality issues disorders 168; and psychosis 133
211–12; stigma and prejudice associated
with 201 McDonald, A. 205
International Classification of Diseases see McGill, P. 205
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ICD magnification/minimisation 119

International Classification of Functioning, malignant social psychology 242
Disability and Health 203 Manpower Advisory Service (MAS) report
internet-delivered therapies 126 (1989) 276, 278
interpersonal relationships: and borderline manual-based approach 23
personality disorder (BPD) 155, 156–7; Maudsley model (eating disorder treatment)
and brain development 79; and dementia 66–7, 177
238 MCMI-III 153
interpersonal therapy (IPT) 21, 66, 67, 99, medical model 38, 41–2
100; eating disorders 173 medicalisation 25, 95
intervention 10–11; effectiveness of 20; medically unexplained symptoms (MUS)
efficacy of 20; evaluation of 11–12; 231, 232
see also under specific disorders medication: administration of 40; anti-
intrusive memories of trauma 183–4, 184, depressants 20; antipsychotic 136, 144,
186 243; borderline personality disorder
IQ tests, and intellectual disabilities 8, 204 (BPD) 158
Melzack, R. 222
Jacobson, N. 100 memory 261; and dementia 242–3; false 192;
‘jumping to conclusions’ reasoning 119, 135 trauma 183–4, 184, 186, 188
Mental Capacity Act (MCA) 178, 260
Kendall, P. 65 mentalisation, breakdown of 156
Kiecolt-Glaser, J.K. 223 metacompetences 24
Klerman, G. 100 mind–body dualism 231, 232
mindfulness 108, 139; and intellectual
La Vigna, G. 205 disabilities 206; and psychosis 139, 140,
labelling: diagnostic 25, 41, 42, 62; self- 119 143, 144
language in mental health, mindfulness-based cognitive therapy
acceptable/unacceptable 43 (MBCT) 21, 66, 95, 99, 108, 224
Lasègue, E.-C. 171 Moos, R.H. 220
Layard, R. 277 motivational interviewing 176, 178
Lazarus, R.S. 222 Mowrer, O.H. 117
leadership 296; clinical 46–7, 281–2, 283; multi-agency working 71–2
consultant clinical psychologists 13, 15 multidisciplinary teams (MDTs) 12, 37–53,
learning disabilities see intellectual disabilities 125, 276; clinical psychologist’s role in
learning theory 27 39–40, 45–7 (clinical leadership 46–7,
Lewinsohn, P. 100 281–2; staff support 47; team formulation
life history work 242–3 45–6); differing perspectives on human
lifespan issues, and physical health concerns distress 41–5; professional roles within
220–1 38–41; see also team working
Linehan, M.L. 156 multisystemic therapy 81
 308 INDEX

narrative approaches 32, 82 partnerships of care 279

National Dementia Strategy 237, 249 pathway model of treatment, borderline
National Health Service (NHS) 274, 292 personality (BPD) 157, 158, 163
National Institute for Health and Care patient, as a term 4
Excellence see NICE Pavlov, I. 27
negative automatic thoughts 94, 103, 108 peer support workers 41, 143–4
negative core beliefs 103, 106 peer-led interventions, for parents 80–1
neuroimaging 267 Penn State Worry Questionnaire (PSWQ)
neuropsychology 254–69; areas of practice in 121
256–7; and assessment 258–62 (for perfectionism, and eating disorders 168, 173
capacity 260; for diagnosis 259; fixed person-based cognitive therapy (PBCT) 139
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battery approach 267; flexible battery or person-centred care, dementia 244

hypothesis-led approach 267; formal tests person-centred recovery 72
238, 258, 267; for formulation 260–2; personality disorders 42, 96, 114, 150–4;
main purposes of 263; for profiling development of 152–3; diagnosis 153–4;
function 259–60); background to the field epidemiology 154; see also borderline
255–6; case study 264–6; and dementia personality disorder; emotionally unstable
238; and rehabilitation 262–4; team personality disorder (EUPD)
working 267 Ph.D. opportunities 298
neurotransmitters 97, 135 phobias: agoraphobia 21, 28–9, 114, 115;
New Ways of Working Initiative 230 social 21, 116; specific 115, 116, 118
NICE recommended treatments 21, 42; phrenology 255–6
anxiety disorders 21; bipolar disorder 21, physical health problems and psychological
82–3; borderline personality disorder 21; distress 132, 216–35, 280–1; adjustment
cancer care 231; dementia 242; depression issues 220; aetiology 222–3; and bio-
21, 66, 82, 99, 101; eating disorders 21, psychosocial theories 222; case study
66, 82, 172; obsessive compulsive 224–31; co-morbid difficulties 218–19,
disorder (OCD) 83; psychosis 136; PTSD 221–2; cognitive problems 218; and
21, 186, 188; schizophrenia 21; coping styles 220; cultural issues 221;
suicide/self-harm 82 diagnostic issues 231–2; epidemiology
non-directive supportive psychotherapy 66 221–2; existential issues 221; gender issues
nursing assistants 41 221; and health/illness beliefs 220, 222;
interventions for 223–4; (acceptance and
obesity 82, 177–8 commitment therapy (ACT) 224, 230;
obsessive compulsive disorder (OCD) 21, 83, cognitive-behavioural approaches 223,
113, 115, 116, 118; and anorexia nervosa 224, 228; integrative therapies 224;
(AN) 170 mindfulness-based cognitive therapy 224;
occupational therapists (OTs) 40 systemic or family-based approaches
online therapies 126 223–4); lifespan issues 220–1; and long-
operant conditioning 27, 28, 117 term conditions 221–2; multi-disciplinary
Oregon treatment foster care 81 team working 224, 230–1; and nature of
the illness 218; religious factors 221; self-
pacing, and pain management 223 management approaches 224; stigma
pain: experience of 222; gate-control theory issues 221
of 222, 228; management 223, 224 physiological response to anxiety 114
panic disorder 21, 113, 115, 116, 118–19 Pincus, H. 222
paranoia 145 positive behaviour support 204–5
paranoid delusions 132 positive social psychology 242
parents 59, 63, 80; peer-led interventions for post-traumatic stress disorder (PTSD) 21,
80–1 115, 116, 118, 120, 182–96; aetiology
Paris, J. 157 185, 186; and avoidance behaviour 184,
 INDEX 309

186; biological factors 186; and borderline psychology graduates, career choices for
personality disorder (BPD) 153; case 288–9, 297–8
studies 188–90 (London bombings (2005) psychometrics 258, 267
190–1); Cognitive Model of 187; psychoneuro-immunology (PNI) studies
complex PTSD 184, 185; diagnosis 223, 274–5
184–5; epidemiology 185–6; psychosis 114, 130–49; acceptance 139;
interventions for 21, 186–8 (eye aetiology 134–6; bio-psychosocial
movement desensitisation and approach 136; biological factors 134, 135;
reprocessing (EMDR) 186, 187–8, case study 139–43; diagnosis 133; early
189–90; three-phased approach for intervention 173; employment
complex PTSD 188; trauma-focused interventions 136; epidemiology 134;
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cognitive-behavioural therapy (TF-CBT) information processing biases 135, 138;

186, 187); interventions for (cognitive-behavioural
NICE recommended treatments for 21, 186, therapy 136, 138, 144, 145; family
188; psychological difficulties that may interventions 136, 138–9, 144);
occur with 183–5, 186, 192; risk factors medication 136, 144; mindfulness
for 185–6; triggers 183, 186, 187 practices and 139, 140, 143, 144; negative
poverty 136 symptoms 132; NICE recommended
Prader-Willi syndrome 201 treatments for 136; and physical health
pre-diagnostic counselling 259 132; positive symptoms 132, 138;
pre-morbid personality 265 prevalence 134; prognosis 136;
prevalence: anorexia nervosa (AN) 171; psychological difficulties that may occur
anxiety disorders 114, 116; dementia 239, with 131–3; psychological factors 134,
248; personality disorders 154; post- 135; recovery-oriented practice 144;
traumatic stress disorder (PTSD) 185; safety issues 132; self-beliefs 135, 142–3,
psychosis 134 144; and sleep difficulties 145; social
prison population: and intellectual disabilities factors 134, 136; team working 143–4;
212; and personality disorders 154 and worry 145
problem solving: negative orientation to 122; psychosocial development, theory of 59, 60
positive orientation to 124; structured 28 psychotherapy 275–6, 297
prognosis, psychosis 136
prolonged exposure therapy 187 qualitative evaluation information 11
psychiatrists 39 quality of life 11, 25, 44, 205, 218, 219,
psycho-education 40, 125, 186, 228, 265–6 220
psychoanalysis 275 quantitative evaluation information 11
psychodynamic models of depression 98
psychodynamic psychotherapy 9, 10, 21, Rachman, S. 275
30–2; intellectual disabilities 205–6; randomised controlled trials (RCTs) 20, 22,
short-term (MBCT) 21, 26, 30, 31–2 23
psychological factors: anxiety disorders 117; rape 185, 187
depression 98; psychosis 134, 135 Rayner, R. 117
psychological measures/tests 8, 11 recovery, person-centred or social 72
psychological model 38 recovery colleges 45
psychological practice, art and science of recovery-oriented practice (recovery model)
19–36 25, 38, 43; borderline personality disorder
psychological therapists 39–40 (BPD) 158; eating disorders 172; and
psychological therapy: core models in clinical psychosis 144
psychology practice 26–33; see also referral information 5
behaviour therapy; cognitive-behavioural reflection on and in action 24
therapy; short-term psychodynamic reflective-practitioner model 12–13, 20,
therapy; systemic therapy 24–5, 86–7, 280
 310 INDEX

rehabilitation, and neuropsychology sexual offending 212

262–4 sexuality, and people with intellectual
relapse, and depression 108 disabilities 211–12
relationship skills 8 Shapiro, F. 187
religious beliefs 221 Sheidlow, A.J. 81
‘reliving’ 187 shell-shock 183
reminiscence therapy 242, 243 short-term psychodynamic therapy 21, 26,
research 16–17, 275 30, 31–2, 99, 101
research careers 298 ‘should’ statements 119
research evidence 20–1 Siegal, D.J. 79
research skills and experience 291, 293 Skinner, B.F. 275
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resilience 47, 293 sleep problems: hypersomnia 96; insomnia

risk factors: dementia 240; post-traumatic 96, 132, 219; and physical health
stress disorder (PTSD) 185–6 problems 218, 219; post-traumatic stress
risk management, eating disorders 169 disorder (PTSD) 183, 184; and psychosis
Rogers, C. 101 145
rumination 108 social anxiety disorder 65, 115, 132
social deprivation 136
safety issues, and psychosis 132 social factors: and childhood mental health
Schein, E. 281 difficulties 63; and depression 96, 98;
schemas 29 and psychosis 134, 136
schizoaffective disorder 133 social learning theory 117
schizophrenia 21, 133, 173, 222 social phobia 21, 116
schizophrenia spectrum disorders 134, social recovery 72
138 social support 224, 226; and depression 96;
Schon, D.A. 24 and PTSD 186
school counsellors 64 social workers 40
SCID-II 153 somatic symptom disorder (SSD) 231–2
scientist-practitioner model 9, 20–2 specific phobias 115, 116
self-beliefs, and psychosis 135, 142–3, spiritual beliefs 221
144 starvation syndrome 168, 172, 178
self-efficacy 119, 226 STEPPS (systems training in emotion
self-esteem issues 132, 133; dementia 238; predictability and problem solving) 157,
eating disorders 168, 169, 173 163
self-harm 61–2, 82, 156, 157, 158 stigma: and intellectual disabilities 201;
self-help interventions: anxiety disorders and physical health problems 221
126; depression 100, 101 ‘strange situation’ test 161
self-management approaches: and bipolar strategic systemic therapy 32, 82
disorder 159; physical health problems Stratton, P. 78, 82
224 Strengths and Difficulties Questionnaire
self-reflection 290, 293 (SDQ) 68
self-report measures 11 stress 223
separation anxiety disorder 65 stress inoculation training 28
serotonin 97 stress–vulnerability model 134–5
service managers 38–9 structural systems model 32, 82
service-user, as a term 4 structured problem solving 28
service-user movement 279 substance misuse 156, 178; children and
severe and enduring EDs (SEEDs) 178 young people 82; and depression
sexual abuse 136, 156, 192; see also rape co-morbidity 96
sexual dysfunction, and physical health suicide/suicidality 82, 96, 132, 169; and
problems 218, 219 physical health problems 222
 INDEX 311

supervision 12, 13, 15–16, 280, 291, 292, and physical health problems 222;
293 vicarious 192–3; see also post-traumatic
support networks: clinical psychologists 293; stress disorder (PTSD)
see also social support Trauma Screening Questionnaire (TSQ)
support workers 41 191
sympathetic nervous system 223 trauma-focused cognitive-behavioural
systemic family therapy 32–3, 77–9; case therapy (TF-CBT) 186, 187
study 83–6; effectiveness and different triggers, post-traumatic stress disorder
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types of 81–3 (PTSD) 183, 186, 187

systemic practice/therapy 9, 10, 26, 78–9, twin studies: anxiety disorders 116;
223–4, 264 depression 97; psychosis 135
systemic theories, of depression 98
uncertainty, intolerance of 121
talking therapies 101, 204, 205–6, 277, 278 unconditional positive regard 101
Taylor, J. 206 unemployment 136
teaching 16 United Kingdom Council for Psychotherapy
team working: anxiety 125; borderline 297
personality disorder (BPD) 162; dementia unmet psychological needs 241–2
247–8; depression 107; eating disorders
177; intellectual disabilities 210–11; validation therapy 247
neuropsychology 267; physical health Van der Hart, O. 192
problems 224, 230–1; psychosis 143–4 Vascular dementia 237
teams: interventions to 11; leadership 15; see vicarious trauma 192–3
also multidisciplinary teams (MDTs) voice hearing 131, 132, 138, 145; ABC
theory–practice links 9 model 140–1, 142; case example 139–43;
therapeutic relationship 8; borderline and personal control 141–2
personality disorder (BPD) 155
thought disorder 132 Wall, P.D. 222
thought records 105, 105, 106 Watson, J.B. 117
Weissman, M. 100
Time for Action report 243 Wellness Recovery Action Plan (WRAP) 44
time-limited dynamic psychotherapy 30 Willis, T. 205
Tourette’s syndrome 282 Willner, P. 205–6
training 16, 39, 274, 275, 276, 277–8, 280, women: borderline personality disorder
282–3, 291; applications 296–7; choice of (BDP) 154; and depression 96; eating
course 290; entry requirements 292–3, disorders 171; post-traumatic stress
296; equal opportunities in 293, 296; disorder (PTSD) 185
funding 292; routes to 295–6; timing of World Health Organisation (WHO) 203,
290 204
trans-diagnostic model: anxiety disorders worry/worries 121–2, 122–4; beliefs about
126; eating disorders 177 121, 124; hypothetical 124; and psychosis
transference 31, 32 145; real current 124
trauma 132, 136; broadening the definition
of 193; differential responses to 186; young offenders 62, 154
intrusive memories of 183–4, 184, 186; young people see children and young people
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