Doctoral Presentation Jan 2009

Clearing the cobwebs of misunderstanding about emotional distress Psycho-educational booklets for Primary Care . Background context . Motivations . Methodologies . Knowledge and outcomes

Secondary Care – open-ended therapy, minimal waiting period Primary Care – brief therapy, lengthy waiting periods

8½ whole-time equiv. therapists 9 counsellors (6 wt equiv) 3 psychologists (2½ wt equiv) Primary Care Psychology & Counselling Service South West Kent 40 surgeries 120 referrals per month Can serve 800 referrals per yr Receive 1500 referrals per yr Brief therapy : 6-10 sessions + 1 PC Mental Health Worker

Demand for psychology & counselling in Primary Care is high 1 in 4 GP patients present with a mental health problem

Waiting Lists Our service : 5-12 months 85% Primary Care counselling services have lengthy waiting lists (Burton, 1998) Impacts on : - clients and their families  distress - therapists – professionally unethical + pressure - GPs – need to hold while waiting + pressure

Government Recommendations National Service Framework (NSF) – 1999 - reduction of stigma through public education - more consistent advice available to those in need - improving access and delivery of services NICE guidelines (National Institute of Clinical Excellence) 2004/5 - self-help literature - psychological therapies - medication

Stepped Care – less intensive, less intrusive first - self-help literature - guided self-help – CBT trained non-therapist ** - Early Assessment - 1-2 sessions early intervention ** - brief therapy – individual and group ** - longer term therapy Group therapy : - Anxiety Management - Assertion - Anger Management - Depression* - Social Phobia*

Motivations for the project Secondary Care  Primary Care open-ended, minimal wait brief therapy, long wait Meeting with people I noticed : suffering for all that time difficulties had become entrenched self-esteem had suffered relationships had often suffered a sense of helplessness and powerlessness evident perceived as personal failing or weakness wished they had understood sooner Reading referrals  frustration & desire to share knowledge to : Increase understanding, self-empathy, self-compassion Provide guidance for self-management

Early assessments - a lot of information communicated - when distressed memory & concentration affected - need may be to listen & encourage emotional catharsis Brief therapy - time is a premium - approach or difficulty may not allow psycho-educative info - need may be to listen & encourage emotional catharsis - a lot of information relevant to many, if not all Group therapy - information as a guide for therapists and supplement for clients Provide booklets as an adjunct to Early Assessment, Brief and Group therapy Resource for therapists and clients, and also able to be shared with loved ones Motivations (cont.)

Motivations (cont.) Resource for GPs - provide an alternative to medication while waiting - psychological ‘treatment’ option for those choosing not to access therapy services - can be provided very early in the piece - educate themselves about psychological understandings

“ CBT-all-the-way” - going against the grain.. More than CBT manuals  relational and generic - pure CBT not a good fit for services offering a variety of orientations - experience in psychodynamic, person-centred, CBT, hypnotherapy, EMDR - colleagues of various orientations – each has value - Psychodynamic, person-centred, Gestalt, TA as effective as CBT - therapist qualities and therapy relationship most important factor - CBT effective for some, not appropriate for all - not all clients like CBT

CBT in the NHS 2003 1000 Graduate Primary Care Mental Health Workers (GPCMHWs) – 2003 - non-psychotherapists trained in CBT  guided self-help CBT - no impact on waiting lists - still required therapy with qualified therapist 2006 Improving Access to Psychological Therapies (IAPT) - £173 million for 3600 non-psychotherapists trained in CBT - currently being implemented

Motivations (cont.) Learning from own experiences and from psychotherapy encounters, in addition to trained knowledge Five types of emotional distress explored : - Anxiety - Depression - Post Traumatic Stress Disorder - Bereavement - Social Phobia Selected for : - prevalence and - personal and professional knowledge and experience

What did I do and how did I do it? Three major components : - exploring the phenomena - identifying & communicating beneficial concepts & methods - creating, evaluating and refining the narratives  booklets  implementing the booklets in Primary Care

Methodology Phenomenological Inquiry – inspiring and reflective of goals To capture the essence of a phenomenon through exploring the lived experience of it as independent of existing knowledge as possible

What did I do? 1st person inquiry – explored my own experiences 2 nd person inquiry – explored the experiences of others - written descriptions from those awaiting therapy - analysis of case notes Concentrated ‘mulling’ periods Synthesis of knowledge Reflection on individual and group psychotherapy encounters Self-help – reflected on own experiences & psychotherapy encounters

How did I do it? Evaluation & Refinement of the Narratives provided to colleagues and clients for informal feedback provided to participants and Early Assessment clients with a guided feedback questionnaire piloted in two of our largest surgeries  communal perspective

The Narratives Holistic experience – essential features Precipitating events Elements of experience - emotional - physical - perceptual/cognitive - behavioural - relational Self-help methods and strategies

The Discoveries.. PTSD - 1 st person experiences - single incident trauma in childhood + cumulative trauma period as a young adult  concurrent post-trauma - single incident traumatic experience in late 20s - deeper level response emerged

First post-trauma experience - triggered watching a documentary about a similar experience - suddenly overwhelmed with emotion - memory flooded back into the present - emotion re-attached to memory

Second post-trauma experience : - traumatic assault - numb and detached - overwhelming need to get as far away as possible - physical and emotional distance from others - felt easily intruded upon - wary – on the lookout for threat - uncomfortable with anger, aggression, dominance - saw threat in innocent/innocuous people/situations - holding breath – waiting for ‘something’ to happen

Statements extracted from written descriptions & case notes Past projected into the present It’s like a demon haunting me. Why? I’d shut it out for years. I’m reliving it. Heightened sense of threat and vulnerability (for self and others) I constantly feel like I’m in danger. I see everything as threatening. I feel gripped by fear. I feel very vulnerable. I imagine awful things are going to happen to family. I see images. I can’t walk my dog without fear of him getting stuck in a rabbit hole.

Hypervigilance to threat It’s like I’m in a combat zone – always looking for danger. I ring my partner all the time to check he’s ok. I look around all the time scanning, thinking I’m going to be attacked. I check all the time. If I don’t look, someone could be there. Defensive, protective behaviours - loss of trust and security I’m scared to take the barriers down. Now I don’t let anyone in. I feel strangled in a relationship, and just want to get out. I’m afraid of trusting. I’m very wary, suspicious of others. I won’t let someone else drive me. I avoid driving myself. I don’t trust other drivers. I don’t trust myself.

Hypersensitivity to perceive threat I always think if someone looks at me, they’re going to attack. A new friend has a fridge in his garage. I thought he was keeping a dead body in it. I saw an old man with a shovel when I was walking the dog. I thought he was burying a body. I think others are going to attack if I look at them. I have a thing about people waiting behind a tree to slash my throat. A sense of powerlessness and need to feel in control I feel like I’m not in control of myself and I don’t like it. Someone else has that power to take us out – like they did these people. I need to feel in control. In my dreams I feel small, powerless.

Imaginal protective defenses When I feel threatened, I get images of attacking others, dominating others and I feel good, powerful, invincible. When I walked past him I imagined him attacking me and myself grabbing the shovel and hitting him over the head, over and over.

Intersubjective inquiry and immersion.. Developing awareness of similarities in presentation Projection of threat onto innocuous others universal Interpersonal protective/defensive hostility only in response to trauma involving personal violation Defensive/protective against fear of exposing vulnerability  emotional, physical, sexual, ‘spiritual’ annihilation Observed from : Personal experience + written descriptions + case-notes + reflection on past & present psychotherapy encounters

Essence of Post Traumatic Stress.. Extreme and active sense of threat in the immediate present Depression  focus on undesired past Anxiety  focus on unpredictable future Post trauma  avoidance of the past blanking of the presence of a future focus on the immediate ‘threatening’ present Motivated by : - heightened sense of threat and vulnerability - loss of trust in the safety/predictability of others/environment - efforts to avoid, escape or protect the self from potential threat

Post traumatic stress.. - past projected into the present - emotionally detached from surroundings and others - energy acutely alert and focussed on keeping self/others safe - heightened perception of own and others’ vulnerability - on guard – waiting for something to happen - fears projected onto innocent situations and people - protective/defensive behaviours - fear of exposing vulnerability or weakness - avoid looking back but the past keeps intruding - trapped in a present dominated by the past

The Four Elements of Anxiety Situation perceived as unpredictable or uncertain - unsure how the situation will turn out - unsure how will react or handle the situation - unsure about ability to handle the situation Belief that you lack control - over event itself - over physical and emotional reactions to event (anxiety itself) Prediction or fear of a negative outcome - perceived as undesirable, intolerable and/or unacceptable Feel hindered, blocked or trapped - from escaping the situation and/or the associated feelings of anxiety - from potentially achieving some desired outcome

Extract from client written description.. “ When anxious I often think – “this is doing me harm, my body, and it’s going to kill me”. “My body won’t cope with all the chemicals it’s making” “I’ll have a heart attack.” “I’ll collapse.” , “then what will I do?” “How do I get help?” “What about the people with me? Will they be able to help?” Unpredictability of outcome – Then what will I do? Prediction or fear of a negative outcome – Death, heart attack, collapse Perceived lack of control – How do I get help? Feel hindered, blocked, trapped from preventing – Will they be able to help me?

Complementary inquiry.. Bereavement - exaggerated perception of omission or commission  guilt - guilt often a factor in ‘unresolved bereavement’ - holding onto the bereavement as a punishment  unresolved - not ‘chronic depression’ but ‘unresolved bereavement’

Unresolved bereavement.. “… .. I feel guilty because I was resentful of my mum’s illness and dependency on me, before she died. Dreams/nightmares have increased recently : ..my mum has gone on holiday and I am left at home, but I don’t know when she’s coming back ..my mum is alive but everyone else thinks she’s dead. Sometimes this makes me feel like a fraud.”

FAULTY FILES I’m not ok.. You’re not ok.. I’m vulnerable You’ll hurt me  don’t trust others don’t let others get too close critical dominating bullying (small %age of people) Nice but also wary Nice ( ≠ perfect) Filter through which you view other people and situations. Also represents your protective defensive shield i.e. strategies you employ to defend/protect yourself from feared outcomes such as negative judgement, rejection, disapproval. critical dominating bullying aggressive violent abusive Negative Past Experiences What You See What is.. FAULTY FILTER

FAULTY FILES I’m not ok.. You’re not ok.. I’m vulnerable You’ll hurt me I’m not safe You’re dangerous I’m not in control You’re not trustworthy  don’t let others get too close FAULTY FILING CABINET FUNCTIONAL FILES I’m ok .. You’re ok .. I’m powerful & have You could be decent nothing to fear You might be trustworthy I’m safe where I am. I’ll take a chance on you I create my own security I trust that you’ll respect me  I’ll be careful, but I’ll give others a chance until I know for sure whether or not they’re trustworthy FUNCTIONAL FILING CABINET Dump the old faulty files.. Start gathering some new functional files..

Refining the Narratives.. Depression…. What is it? And what can I do about it?? !! Anxiety !! What is it? And what can I do about it?

Losing Someone You Love.. Post Traumatic Stress Disorder (PTSD)

The symptoms of depression can be divided into four sections : - emotions or feelings - physical or bodily symptoms - behaviours - thinking / thoughts / perceptions

**You could tear off or copy the list below and place it somewhere to hand eg in a wallet or purse, near your phone or at a bedside table.** ---------------------------------------------------------- Who to Ring When I Really Need to Talk ____________________________________ ____________________________________ ____________________________________ ____________________________________ _____Samaritans _____ 08457 909090 ___ “ Provided light relief“ “ The pictures help a lot. Easy to scan and see what was relevant. I really liked the boxes. It was all ready to be used and telling you to take control of the situation.” “ I like the writing style. It conveys a really positive message.” (GP)

Anxiety booklet.. Gulp.! Gulp.! Gulp.! Woohoo! Anxiety can vary from mild to extreme according to how threatening you perceive the situation to be.

Social Phobia booklet.. Sometimes the person targeted just happens to be in the wrong place at the wrong time when a bully is looking for someone to victimise.

Confirmation.. Colleagues “ I love the pictures.” “ I really like the characters. They’re quite witty and lighten up the mood. I think this will help people feel less alien.” Participants “ Thank you!! Very much. The up-beat way of writing has taken away the worry of anxiety. I know now what I suffer and have a good idea why and best of all what I can do about it!”

Feedback from colleagues.. “ I really enjoyed reading the booklets and found them very informative.” “ These are well researched, lots of information.” “ It is very well done, I have learned a lot from receiving your project. “ “ I think this is a really useful piece of work and would like to have a copy when you’re concluded! I hope my comments are helpful – mostly on sentence structure etc. – content’s great!” “ This is phenomenal. I have total admiration for how much you’ve put into these and wondered how on earth you’ve done it.” “ Many thanks for preparing all these – they look excellent; really clear and positive. I’ll start using them on selected patients.” (GP) “ You’ve done really well to write these in a style that suits all.”

Feedback from clients/participants.. “ I read a lot of the depression booklet last night. I'm really impressed, it’s great and very well written. My first reaction was one of relief that I could say that I can relate to the information I'm reading and I don't feel so alone. This gave me hope and I felt eager to read more.” “ The knowledge that your body is designed to respond in this way and can easily handle it is very reassuring.” “ I completely agree that finding a therapist with whom you feel comfortable is more important than the actual approach. At the time I thought I was failing with my second counsellor, but I now realise this was not the case. Other helpful suggestions, p60 focussing on others, p83 Lifeline – makes you think about contributing experiences that lead to depression and p64 Writing – I found this helpful.”

Feedback from clients/participants (cont.) Telephone Message : “ He has received the PTSD information. It unnerves him that you have got into his brain. You couldn’t be more exact if you’d tried. He thinks it is spooky – he is going to call you Mulder in future. He feels very positive and will have a lot to talk about at his next appointment.”

Feedback from clients/participants (cont.) On the language of the booklets : “ Very easy to understand. Not woolly. Informative and straightforward.” “ Not condescending and the author gives the impression of really understanding depression and offers helpful suggestions.” “ Very easy to understand. Very in depth and interesting.” “ Having read a lot of booklets on anxiety given to me from past psychologists, I have read a lot of the same information over and over again but I found this booklet wasn’t unnecessarily long and there was a lot of useful, in depth information.”

Feedback from Group Members “ The handouts were informative and challenging and I found them very helpful to re-read at home. It helped me to re-affirm some of the group sessions. I have referred to the information several times.” “ Looking back at them has shown me that I have become much more stable with the depression aspect of my emotions.” “ The handout information helps to refresh my memory. It’s like going to the group but not. You have something to take in and read. That has been very helpful since finishing the group.”

The electronic era.. Accessible directly from GP via surgery website : “ I think this is the best idea. Helping people understand that help is out there and you can try and help yourself through it. I would have felt a little more comforted if I had had this information sooner.” recently implemented at the two pilot surgeries time and cost effective

Feedback from clients/participants (cont.) “ It gave me an overwhelming understanding. The way you word it is just right. I gained a real understanding of why. This is the first time I have ever felt so understood. There were so many things that fitted. When I was attacked something snapped. Now I’m more self aware of the reactions I’ve had since the attack. I’m more aware of the extent of PTSD related symptoms. . . . I really did relate to the way you worded it. The way you simplify it to a mediocre way of explaining it, even though you have all that professional knowledge and words. You feel like you’ve achieved some understanding. And the saying, ‘That was back then, this is now’ – do that now, say it to yourself. That has helped me so much. I say that to myself. I realise now, I have got a good future ahead of me. I have a sense of calm, of being who I really am. I feel like I’ve crawled out of the flames.”

Doctoral Presentation Jan 2009

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Doctoral Presentation Jan 2009