Psychological best practice in inpatient services for older people

Transcription

1 Faculty of the Psychology of Older People Psychological best practice i ipatiet services for older people Edited by Kate Ross & Sarah Dexter-Smith November 2017

2 The British Psychological Society 2017 All rights reserved. No part of this report may be reprited or reproduced or utilised i ay form or by ay electroic, mechaical, or other meas, ow kow or hereafter iveted, icludig photocopyig ad recordig, or i ay iformatio storage or retrieval system, without permissio i writig from the publishers. Equiries i this regard should be directed to the British Psychological Society. British Library Cataloguig-i-Publicatio Data A catalogue record for this book is available from the British Library. ISBN Prited ad published by The British Psychological Society St Adrews House 48 Pricess Road East Leicester LE1 7DR If you have problems readig this documet ad would like it i a differet format, please cotact us with your specific requiremets. Tel: ; P4P@bps.org.uk.

3 Psychological best practice i ipatiet services for older people Edited by Kate Ross & Sarah Dexter-Smith This publicatio has bee produced by the British Psychological Society Divisio of Cliical Psychology ad represets the views ad expert cotributios of the members of that Divisio oly. For all equiries, icludig obtaiig a prited copy of this documet, please memberetworkservices@bps.org.uk (puttig Psychological best practice i ipatiet services for older people i the subject lie) or telephoe ISBN: British Psychological Society 2017 i

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5 Cotets Executive summary 3 Itroductio 7 Chapter 1: The key psychological offer 11 The overarchig cocepts of cotaimet ad compassio 14 What works for ipatiet psychologists? 15 Assessmet ad formulatio 16 Itervetios 16 Traiig 17 Summary 17 Refereces 18 Chapter 2: The patiet jourey 19 The experiece of arrival 20 Key tasks durig a stay o a ipatiet uit 21 Coectig 21 Goal settig 21 Idetifyig the road to recovery 21 Maitaiig or re-establishig idetity 22 Maitaiig ad establishig attachmet 23 Re-establishig a sese of competece 23 Re-establishig a sese of comfort 24 Maitaiig ad promotig iclusio 25 Re-establishig hope (love) 25 Movig o 26 Whe death is part of the patiet s jourey with us 27 The family jourey 28 Summary 29 Refereces 29 Chapter 3: Therapeutic egagemet 31 Egagig the idividual 32 Egagig families ad other carers 32 Egagig the staff team 33 Self-care for the psychologist 34 The iitial approach 34 Developig agecy 34 Hoour the meaig of the ward team s experiece 35 1

6 Validatig outcomes 36 Addressig potetial barriers ad flexibility 37 Egagig with the whole system 37 Summary 37 Refereces 38 Chapter 4: Psychological formulatio 39 What is a psychological formulatio? 39 Purpose 40 Beefits of formulatio ad reflectio o work 40 Theoretical model, focus ad process 41 Potetial problems ad ways to overcome them 44 Outcomes 45 Summary 45 Refereces 46 Chapter 5: Speakig the ward s laguage 47 Who are you commuicatig with? 50 What are you commuicatig about? 50 Fid a way i 51 Summary 52 Refereces 53 Chapter 6: Culture chage 54 Itroductio 54 What is culture? 56 A framework for culture chage 57 Summary 60 Refereces 61 Chapter 7: Psychological harm 63 Takig thigs forward 68 Refereces 69 Chapter 8: Tips from the coalface 71 Itroductio 71 Relatioships with colleagues 72 What helps? 73 What does t help? 76 Tips from our service user cosultatio group 77 Self-care ad resiliece 78 Cotributors ad ackowledgemets 79 2

7 Executive summary Psychologically healthy wards The Royal College of Psychiatry accreditatio stadards for older people s ipatiet services curretly recommed a miimum of 0.5 wte dedicated cliical psychology time for each ward. It further recommeds that there is adequate cliical psychology resource for the size of uit to esure that all patiets have access to detailed psychological formulatio ad that there is therapy provisio for those who would beefit. The Faculty for the Psychology of Older People edorses this recommedatio. This executive summary outlies what features of a ipatiet service cotribute to the psychological health of ipatiet eviromets for older people, their families ad the staff who work there, ad what cliical psychologists specifically ca cotribute to services. A. Promotig a psychologically healthy eviromet: the psychological wellbeig of people usig ipatiet services is a core compoet of the service offer ad ivolves cliical staff of all professios. The followig factors make a positive cotributio to the overall effectiveess ad quality of care i ipatiet services for older people: 1. The ward has a dedicated psychologist. 2. The service is committed to the recovery model. 3. Psychological care is uderstood to be part of everyoe s role. 4. The psychologist works i partership with the ward maager to promote quality of care. 5. The psychologist offers specialist assessmet, formulatio ad itervetio directly to patiets. 6. The psychologist offers traiig ad models good psychological practice to other cliical staff. 7. The psychologist leads multidiscipliary formulatio sessios ad complex case discussio groups with the multidiscipliary staff team. 8. Psychological resource o the ward is ehaced by the presece of assistats, traiees ad/or iters. 9. People with lived experiece ad iformal carers are ivolved i service developmet. 10. There is a broad ad evely distributed mix of workforce e.g. overall quality of psychological care is also ehaced by the sigificat presece of other therapies staff; occupatioal therapy, arts for health, physiotherapy, pharmacy, speech ad laguage therapy, dieticia, etc. 11. The ward provides patiets with iformatio about what to expect of their stay ad works to make sese of each perso s experiece of their jourey through the admissio. 12. The ward works closely with family or frieds of the patiet s choice. B. Cliical psychology i older people s ipatiet services. Psychology has the potetial to make a sigificat cotributio to cliical effectiveess ad quality i ipatiet services for older people. The research that accompaies this documet idicates that: The impact of the psychology resource is ehaced by clear egotiatio with the operatioal team about what they hope to achieve from their psychology iput. This should clearly map oto what is measured ad evaluated about the iput provided. 3

8 The psychological itervetio that provides the sigle biggest impact o overall quality ad effectiveess of care is psychology led multidiscipliary formulatio of patiets idividual lives, challeges, traumas, stregths ad recovery eeds. Psychologists based withi ward teams ca make a sigificat cotributio to: the overall culture of care; the achievemet of user friedly care pathways ad protocols; developig the service s psychological competecy i commuicatio; icreasig therapeutic egagemet of staff ad patiets; avoidig iatrogeic psychological harm; ad icreasig attetio to all the small gestures a service ca make to icrease a perso s sese of beig welcome, valued, ad cared about. Much of the beefit of psychology comes from workig at a team or service level; providig traiig ad supervisio, promotig recovery ad co-productio, etc. Effectiveess of idividual cliical itervetios i this cotext has bee show for solutio-focused approaches, age-adapted models of CBT ad Midfuless, ACT, DBT, experietial dyamic psychotherapy. Risk assessmet, capacity assessmet, ad cogitive assessmet ca also be a effective use of psychology time. The decisio of how much cliical psychology to commissio at what badig for each uit will deped o what the service wats to achieve from the employmet of psychologists withi the team. The followig is a broad guide to the added value that could be expected of psychologists at differet stages i their career. I order to achieve the maximum impact of psychology described as above i a cost effective way, we recommed a professioal structure of psychologists at differet bads. Employig psychologists with seiority ca deliver improvemet across the service, whilst the employmet of psychologists at lower pay bads delivers a sigificat cliical resource. Assistat ad traiee psychologists provide valuable extra resources but should ot be employed without the appropriate qualified psychologist supervisio ad do ot satisfy the requiremet for qualified psychologists recommeded by CCQI. The followig table is desiged to facilitate local coversatios about workforce plaig withi a safe goverace framework. As such, it assumes that the psychologists withi each bad are supported by a comprehesive seior psychology structure i order to safely deliver these elemets. Kate Ross & Sarah Dexter-Smith 4

9 Iput to the orgaisatio Iput to the cliical service Iput with the staff team Iput with family ad carers Iput with patiets Bad 7-8b *Ivolved i local service/team decisios Bad 8c * Ivolved i cliical goverace strategy *Acts as priciple ivestigator i ivestigatios ad complaits *Supports orgaisatioal learig from cliical icidets Bad 7 *Carries out audit ad research Bad 8a As above plus: *Selects ad desigs outcome measures Bad 7 *Works alogside psychology assistats (both uder directio of more seior psychologists) *Delivers traiig i psychological therapy models ad psychological wellbeig itervetios for other staff Bad 8a As above plus: *Placemets for psychology traiees, assistats ad iters *Cliical supervisio for other staff members *Reflective practice groups Bad 7 *Liaiso work with families *Provides carers support groups *Helps patiets choose how they d like their loved oes ivolved Bad 8a As above plus: *Complex cliical work with families *Develops family ad carer commuicatio ad cosultatio *Systemic therapy itervetios Bad 7 * Oe-to-oe cliical work with patiets *Specialist psychological assessmet *Specialist psychological formulatio *Specialist psychological itervetio *Group therapy itervetios * Neuropsychology assessmets. Bad 7 will eed specialist supervisio by a seior psychologist Bad 8a As above plus: * Iitiates patiet feedback *Leads goal settig with patiets *Develops commuicatio of recovery eeds across services *Delivers complex risk assessmet *Delivers complex formulatios ivolvig multiple morbidity ad physical ad social care eeds Bad 8d As above plus: *Leads orgaisatioal research ad trasformatio *Operates throughout the sub-structures of the orgaisatio *Cotributes to orgaisatioal culture *Advocates orgaisatioal approach to recovery *Advocates culture of co-productio Bad 8b As above plus: *Esures psychological formulatio ad psychological eeds are a itegral part of care pathway *Supports service to be recovery ad patiet cetred *Supports service to be proactive aroud diversity *Helps service to idetify quality idicators for psychological care Bad 8b As above plus: *Offers supervisio to seior cliical staff icludig psychiatry *Applies psychological models to other care tasks *Leads multidiscipliary formulatio *Desigs traiig ad developmet programmes for other staff groups Bad 8b As above plus: * Creates coproductio opportuities for carers i ward Bad 8b As above plus: * Delivers complex capacity assessmets *Desigs ad implemets cliical protocols 5

10 Iput to the orgaisatio Iput to the cliical service Iput with the staff team Iput with family ad carers Iput with patiets Bad 8c As above plus: *Leads research ad audit ad uses data strategically *Iputs to quality ad operatioal processes *Iputs to service visio ad service developmet *Iterprets policy ad atioal drivers for other staff *Adapts care models to meet eeds of people of diversity *Offers team debrief followig icidets *Leads approach to coproductio withi the service *Cotributes at a seior level to overall culture of service *Leads cultural chage Bad 8c As above plus: *Offers metorig ad coachig across staff groups * Formally supports ward maager with team culture Bad 8c As above Bad 8c As above plus: * Secod opiio *May be resposible cliicia Bad 8d As above Bad 8d As above Bad 8d As above Bad 8d As above 6

11 Itroductio This guidace is iteded for psychologists at ay stage of their career who work i ipatiet services. The emphasis is o services specifically dedicated to older people, i particular metal health ad demetia services but the geeral priciples are relevat to all-age ad physical health services where these are providig services to older people. For the purpose of this documet, the term older people refers to people who use services that are desiged specifically for older people or who use services to help them with cliical difficulties that are most commoly associated with ageig. By ipatiet services we mea a place where someoe is livig (short or log-term) for assessmet or treatmet (ot simply social/persoal care) based o their metal health eeds. This would exclude residetial care although some of the priciples will easily trasfer. This documet arose from a groudswell of cliical iterest ad eed. There has bee a huge icrease i the applicatio of psychological theory ad practice across o-traditioal settigs ad icreasigly, this has icluded dedicated psychology iput to ipatiet services. Psychologists have a clear idea of what they would aspire to i ipatiet services for older people. Surveys of the professio udertake as part of the developmet of this documet (Ross, 2015) 7

12 idetify themes of: emotioal safety; parity of esteem; perso-cetred care focused aroud idividual eed; the cetral role of psychological formulatio as a represetatio of the psychological uderpiig of huma experiece; ad the fudametal ecessity of healthy relatioships to eable therapeutic care. Psychologists have whole-heartedly edorsed the improvemets to quality of care ad patiet experiece that result from the iclusio of a psychological uderstadig of people s eeds i ipatiet services. However, ipatiet eviromets preset a cliical cotext that demads a differet rage of skills to those developed i commuity services. Over several years, the Faculty for the Psychology of Older People (FPOP) has worked to brig together a evidece base of published materials, examples of good practice, cliical expertise, ad a uderstadig of the challeges that cliicias experiece. This guidace is the culmiatio of that work. The published evidece base has bee cosiderably eriched by ecouragig cliicias from across the four atios to submit examples of what they are doig i their local services ad to idicate what approaches they have had success with. This iformatio is available o the website pages via the mai FPOP website. The purpose of this guidace documet is to articulate the mai areas that psychologists eed to cosider i order to egage with services effectively. For this reaso, the eight chapters are divided ito themes that reflect the process of plaig psychological egagemet rather tha therapeutic models per se. Throughout the documet, there is cosideratio of ways of egagig at differet levels; with idividual patiets, family members, idividual team members, whole teams, ad the wider orgaisatio. At differet times i a idividual psychologist s professioal developmet ad a orgaisatio s wider developmet, psychologists may be ivolved at ay or all of these levels ad the documet reflects these differet ways of workig. We hope that this documet will: Help psychologists to articulate what they are able to offer ad what is eeded for psychological iput to make a impact. Eable psychologists to fid a voice for psychological work i a eviromet that ca be heavily focused o physical eeds ad medical itervetios. Articulate the psychological evidece base ad key policies. Guide psychologists i prioritisig ofte very limited time to make a oticeable differece ad how to evidece that (ad to whom). Esure that what psychologists offer to services fits with operatioal ad orgaisatioal priorities. Eable psychologists to cosider the use ad goverace of psychologically iformed itervetios delivered by other team members, psychological itervetios delivered by psychologists, ad the use of psychological theory at a systemic level. Idetify the barriers that ca exist i tryig to achieve good ad ways of overcomig them. Show how to work with/withi a team whilst also tryig to shape the team s culture ad support the wellbeig of all those who use the service. Eable psychologists to exercise pragmatism ad develop resiliece i a cliical eviromet that is ofte shiftig ad upredictable. Guide psychologists i workig therapeutically i eviromets where classic therapy ad europsychological approaches may be iappropriate. 8

13 A executive summary has bee produced alogside the mai body of the guidace. This is a respose to the request of may psychologists for a shorter documet that ca be used to facilitate discussios with those resposible for desigig ad commissioig services. The executive summary gives a brief accout of the factors that cotribute to psychologically healthy wards ad outlies what service maagers ca expect from psychologists at differet badigs. The itetio is to help psychologists thik about how the core priciples of psychological theory ad practice apply i ipatiet services ad to provide a meu of ideas ad thigs to try whe the way forward seems opaque. Although the work has bee primarily writte with cliical psychologists i mid (ad fuded by the DCP) may of the ideas will be relevat to psychological practitioers more broadly. Psychologists are ivited to thik about what is immutable ad what eeds adaptig, what the ratioale is for their role i the service, how they ca best support both the team ad the people who use these services, ad what the ageda is of the orgaisatio which has placed them there. There are ow may examples of services that use psychology to good effect, ad the documet will help to articulate what the ratioale for psychological iput might be ad what ca be asked of psychologists at differet stages of their career. Each chapter ca be read o its ow or alogside the other chapters for a more holistic accout. The chapter authors have draw heavily o the work of their colleagues across the Uited Kigdom ad have tried to make a broad assessmet of the available evidece. Psychology is a broad church which happily icludes may differet ideas ad approaches. The itetio is to ecourage curiosity ad creativity amogst psychologists. The authors have take a eclectic approach reflectig a opeess to the rage of perspectives ad ideas that have bee valuable at differet times ad places. I producig the documet, there have bee itese ad fasciatig discussios ad the documet is iteded to sustai ad iform those discussios. We have cosulted widely at each stage of this documet, with service users, carer groups, other professioal bodies ad third sector orgaisatios. Their feedback has bee supportive ad added breadth to the fial documet. The authors are also kee that the documet should embody the values which are core to psychology. Specific cosideratio is give i each chapter to issues of differece ad to ways i which people who use the service ca develop owership, both of their ow care ad of the services desiged to help them. The editors have also thought at legth about the laguage adopted throughout the documet. Laguage is a powerful medium ad The British Psychological Society (2015) has specific guidace o the appropriate style of published iformatio ad the appropriate use of health-related termiology. It is perhaps a reflectio of the difficulty of geuiely ackowledgig the lived reality of people who use our services that the recommedatios of these guidelies cotiue to be debated ad cotested. The editors support the core priciple that people with health eeds are experts i their ow care ad provide ivaluable isight ito the received experiece of usig the service. The editorial decisio about whether to use patiet or service user or expert by experiece or cliet to refer to these people has bee very difficult. Wherever possible, we have talked about people ad idividuals sice it is people s humaity that is most importat to us. However, there have bee istaces where it has bee ecessary to make 9

14 a distictio betwee the people receivig the service ad the people deliverig it ad o these occasios, we have opted to use the term patiet. This is a coscious decisio to use the laguage preferred by ad most frequetly used by older people usig ipatiet services themselves so that they may recogise themselves ad their experieces withi this documet. We also do ot wat to gloss over the o-goig power imbalace that is curretly prevalet i the way that ipatiet services egotiate the care that is provided with the recipiets of that care. There is core guidace ad other sources of iformatio related to each of the fuctios that the chapters address. The authors brief was to build o, rather tha repeat, that guidace but we ecourage you to read those documets alogside this guidace. The purpose of this guidace is to offer a strategic framework withi which those bodies of core kowledge ca be effectively applied. A separate documet by the British Psychological Society focuses o workig age acute ipatiet services (DCP, 2012) ad is worth readig i cojuctio with this guidace. Fially, we wish you well i your edeavours. The examples of good practice that we have collected ad the writig of this documet has ehaced our ow uderstadig of how to approach services ad we hope that this guidace is helpful to you. Kate Ross & Sarah Dexter-Smith Refereces British Psychological Society/Divisio of Cliical Psychology (2015). Guidelies o laguage i relatio to fuctioal psychiatric diagosis. Leicester: British Psychological Society. Divisio of Cliical Psychology (DCP, 2012). Commissioig ad deliverig cliical psychology i acute adult metal health care. Guidace for commissioers, service maagers, psychology maagers ad practitioers. Leicester: British Psychological Society. Ross, K. (2015). Ipatiet workstream. Faculty for the psychology of older people, The FPOP Bulleti. Leicester: British Psychological Society. Statemet of thaks Thaks to all the patiets, carers ad orgaisatios who have worked o this documet. Specific thaks to Jea Hooper for her support i gettig this published ad the authors for all the time ad thought they have put ito their chapters. Artwork provided by Scriberia: 35 Tileyard Studios, Tileyard Road, Lodo N7 9AH 10

15 Chapter 1: The key psychological offer Ipatiet services are complex ad multifaceted systems that operate differetly to commuity services. Patiets ad staff alike report that access to a cliical psychologist is a ivaluable aspect of ipatiet care. Yet psychologists ofte feel bewildered whe they have their first experiece of ipatiet services, strugglig to kow how to egage ad operate i a cotext where there are few of the structures that are familiar to psychology; appoitmets, cliics, referrals etc. At the same time, psychologists ca become acutely aware of the potetial scope to ifluece a critical part of the patiet s jourey as well as effectig chage through the wider workforce. Balacig direct ad idirect work ca itroduce dilemmas, icludig how to optimise a limited resource i a way that complimets the expertise of the wider team. Psychologists eed to thik about their key psychological offer to all parts of the system they are workig i, whether that is patiets, carers/family, idividual ad collective team members, or the wider orgaisatio. The purpose of this chapter is to thik through strategic issues ad the uique cotributios the professio ca make to address them. The evidece relatig to effective use of psychology time is preseted ad the reader is ecouraged to cosider what will ifluece how their time is prioritised ad what it is possible for psychologists to offer at differet badigs. The values uderpiig the use of psychology are idetified. The iitial cosideratio of iterveig via cliical assessmet ad formulatio ad the delivery of traiig is also cosidered. Strategies ad models of itervetio are developed i later chapters. At the time of writig, the most recet Royal College of Psychiatrist s stadards for ipatiet services (CCQI, 2017) recommed that each ward should have access to at least a 11

16 half-time psychologist, but the actual resource available i services across the Uited Kigdom is very variable. The potetial for psychology ivolvemet is almost limitless. Decisios about where to prioritise the time will deped o how much psychology you have available at what grade, the ature ad developmetal maturity of the uit, ad the orgaisatio s aspiratio for what psychology ivolvemet will achieve. The tasks that psychology might typically be ivolved i are give i Figure 1. Figure 1 also gives a broad brush perspective o what it is geerally possible to offer with psychologists at differet badigs i terms of both cliical ad leadership tasks. For each elemet, there is a idicatio of the level of seiority that is most likely to be ecessary for the majority of activity at this level. Clearly, this will be depedet to some extet o the idividual kowledge ad skills of the psychologist i post ad the local arragemets for supervisio ad goverace ad is iteded to be a guide oly. Work outliig the leadership elemets of a psychologist s role withi the NHS Leadership Academy s Healthcare Leadership Model (Dexter-Smith et al., 2015) is publicly available o the North East Leadership Academy s website. Key questios to ask are: Who made the decisio to employ a psychologist i the service ad why? What are the curret service drivers that require that thigs be doe It may seem like a chage i ay policy is rare differetly? But subtle little chages icrease quality of care Where ad with whom is psychology Because there s more tha just pay i which we likely to have most ifluece? fid rewards. You ve got to cosider elemets of What resources do you have at your psychologically mided wards disposal? How much psychology time is Ad although patiets beig agry ad cofused is awful available? At what badig? How much persoal resource do you We re here to help the team be more compassioate ad thoughtful have curretly? Who will be your allies i ay chage? Foud Poetry, October 2015 Where might the resistace lie? How do you positio yourself so that you ca work with the service but also ifluece elemets of the system? What are the service s explicit ad uspoke aims ad values/the culture ad laguage? What is the history of psychology o the ward? How will psychology s cotributio be evideced ad to whom? As well as makig decisios about the balace of time betwee direct patiet cotact, idirect workig through teams, staff support ad traiig, culture chage etc., it is fudametal to start by cosiderig the values ad relatioships that the psychologist wishes to embody. Staff workig withi ipatiet services are carig for the most distressed ad ofte physically uwell older people i our society; they work log shifts ofte i challegig physical eviromets with historically limited access to high quality supervisio. Yet we kow that well supported ad cotaied teams are more likely to deliver compassioate ad good quality care (Firth-Cozes & Corwell, 2009). Psychology is ofte uiquely placed to be able to straddle the positio of team member ad exteral observer. Experiece suggests 12

17 OVERARCHING PSYCHOLOGY DRIVERS: COMPASSION AND EMOTIONAL CONTAINMENT Cliical Tasks The Psychological Offer Leadership Tasks Idividual work with the patiet: cliical assessmet, europsychological assessmet, fuctioal behavioural aalysis, formulatio, idividual & group itervetios, advocacy. Bad 7+ THE PATIENT Establish commuity meetigs & opportuities for service users to ifluece the service. Esure curret psychological eeds & future recovery eeds are reflected i overall care pla. Offer traiig ad supervisio to other staff re: psychological approaches. Bad 7+ Collaborative work with carer/ family, support group, systemic itervetios, cliical itervetios for distressed carers. Bad 7+ CARER AND FAMILY NETWORK Develop ways for patiets to idicate how they would like their loved oes to be ivolved. Support family ad carer commuicatio ad cosultatio strategies. Bad 8a+ Multidiscipliary formulatio, reflective practice groups, staff traiig & supervisio, developmet of cliical protocols ad outcome measures. Bad 8a+ STAFF TEAM Support ward maager with effective team dyamics & appropriate skill developmet, applicatio of psychological models to difficult ursig tasks, metorig ad coachig. Bad 8b+ Esure psychological eeds & formulatio are itegral to care pathways. Support service to be recovery & patiet focused & to treat people from diverse backgrouds with digity & respect. Bad 8b+ THE SERVICE Iput to quality & operatioal processes & service & workforce developmet/visio. Iterpret policy & service drivers. Adapt care models to esure that the eeds of people of diversity are geuiely met. Lead audit & evaluatio. Bad 8c+ Ivolvemet i cliical goverace strategy & orgaisatioal learig from cliical icidets. Bad 8c+ THE ORGANISATION Lead orgaisatioal research ad trasformatio. Commuicate throughout sub-structures of orgaisatio. Cotribute to orgaisatioal culture. Advocate for a culture of co-productio. Bad 8d+ DRIVERS: NATIONAL POLICY, CLINICAL GUIDELINES AND PATHWAYS, LOCAL PRIORITIES Figure 1: The Psychological Offer. 13

18 that eablig teams to recogise, ame ad actively maage their ow emotioal resposes both to their cliical work ad also to the demads of their healthcare system, is a itervetio that is highly valued by ursig staff (BPS, 2001). This is covered i detail i other chapters i this guidace. The modellig of compassio towards ourselves ad others, ad the offer of emotioal cotaimet are essetial elemets that drive the psychological offer. Psychology may be ivolved at multiple levels depedig o the experiece of the psychologist i post ad the priorities of the service, but all cliical ad leadership itervetio is motivated by the fudametal eed for compassio ad emotioal cotaimet. The precedig table assumes that the idividual psychologists are workig withi a well govered service ad have access to appropriate seior psychology support. The table is iteded to support rather tha dictate local discussios. The overarchig cocepts of cotaimet ad compassio If compassio ad cotaimet are the mai drivers for psychology, the what does that mea for our practice? Compassio ad cotaimet are the otios of beig able to hold i mid the emotioal state or situatio of aother; a desire to alleviate or reduce sufferig by offerig a thoughtful space while toleratig ot kowig, thus allowig a sese of beig held ad uderstood. Psychologists are especially skilled i maitaiig uderstadig ad compassio for others whilst cotaiig ad toleratig highly distressig emotioal states. This is a skill that is extremely importat i ipatiet services both i order to help staff cultivate compassio towards themselves ad to maitai therapeutic approaches with patiets or family members who elicit strog emotios. Acute episodes of agitatio or aggressio ca be a particular challege for the maiteace of compassioate ad cliet-cetred care ad psychology ca cotribute to de-briefig from these episodes i a umber of ways. Discussios aroud how to deliver ursig itervetios i which staff are facilitated to ame ad ormalise their emotioal resposes may be a particularly useful way of modellig empathy for all cocered. Although the way of providig cotaimet may differ, key priciples apply ad perso-cetred care remais at the heart of everythig. Cotaimet for the patiet ad family may come through collaborative uderstadigs of their curret cotext ad clear commuicatio about how this will meaigfully guide care. Cotaimet to the staff may comprise uderstadig the pressures of providig cliical care amogst competig cliical ad orgaisatioal pressure especially at times of chage ad ucertaity. Cotaimet to the orgaisatio may come i the form of uderstadig the axieties that arise from a eed to meet performace ad fiacial targets alogside rapidly chagig agedas. The core cotributio that psychologists make to ipatiet services is this cotaimet. If the psychologist is preset ad see as a core team member, the team will trust them with the work that provokes the most axiety for them. This might be through requests for staff support, risk assessmet ad maagemet plas, capacity assessmets or help uderstadig the perceived stuckess of particular patiets. Cotaiig these axieties ca be overwhelmig, especially if the psychologist does ot comprehed the dyamics ad the purpose uderlyig these requests. Robust support ad a formulatio of the system ca allow the psychologist to cultivate compassioate cotaimet for the system at every 14

19 Psychologist models good practice i additio to offerig traiig More evely distributed multidiscipliary resources o wards Dedicated psychology time Awareess of rehabilitatio ad recovery as the model of choice Shared resposibility for makig the psychological delivery work What cotributes to good psychological care i ipatiet services? Psychologist offers specialist assessmet, formulatio ad itervetio Service iformed by patiets ad carers Service provides iformatio o what people should expect of a ipatiet stay Figure 2: What cotributes to good psychological care i ipatiet services? Regular presece Staff traiig Availability of assistats, traiees, iters Modellig priciples of coproductio ad iclusivity Close relatioship with ward maager ad egagemet i the quality ageda What do psychologists do that works i ipatiet services? Specialist psychological assessmet ad formulatio Staff egagemet ad support, supervisio ad reflective groups Figure 3: What do psychologists do that works i ipatiet services? level ad respod to requests i a midful way. A additioal aspect of compassioate care is the service s ability to embrace the idividuality ad diversity of all the people who use it. Psychologists have a role i helpig the orgaisatio to be midful of how it achieves iclusio ad makes people welcome. The ways i which psychologists ca egage with the culture of care are discussed further i chapter 3. What works for ipatiet psychologists? As part of the preparatio for this guidace, FPOP udertook a series of exercises gatherig examples of good practice ad lookig for a cosesus of opiio from experieced practi- 15

20 tioers. The full details of the examples that were collected ca be accessed via the website that accompaies this documet. A summary of the fidigs is give i Figures 2 ad 3. Assessmet ad formulatio Psychologists highly specialist assessmet ad formulatio skills are particularly useful for guidig care that is resposive to multiple ad co-morbid psychological, physical ad social eeds. Psychologists are regularly asked to cotribute to complex decisio-makig aroud risk ad capacity. Capacity decisios ofte relate to fiaces ad future accommodatio but also, ot ifrequetly, ca cocer how someoe wishes to approach the treatmet of their physical health eeds. Psychologists i ipatiet services ofte fid that they eed to acquire a kowledge base i physical health as well as makig sure their kowledge of the metal capacity ad metal health legislatio is curret. Of all the ways that psychologists cotribute to ipatiet services across the Uited Kigdom, the itervetio idetified i the examples of good practice with the most cosistetly positive outcome is the delivery of psychological formulatio discussios with staff. Psychologists use a umber of theoretical models to structure these (see Dexter-Smith, 2010; James et al., 2010) ad the complex issues surroudig this provisio are outlied i Chapter 4. Fudametally, perso-cetred care relies o the whole workforce makig sese of experieces from the perspective of the patiets ad families we work with. Through traiig, staff ca lear about formulatio, what makes it distict from a purely biomedical perspective ad how this biomedical perspective ca leave people feelig disempowered. Embeddig formulatio ca offer patiets ad staff a platform for ope dialogues that have the potetial to powerfully shape the arrative the orgaisatio holds. Itervetios Kowledge ad delivery of evidece-based itervetio is a further key offer that psychologists ca make. Psychological therapy ca be beeficial i ipatiet settigs (Kösters et al., 2006), particularly ope therapy groups, which are based o skills learig or distress tolerace. It pays to be midful of the purpose of itervetio i the ipatiet cotext ad the potetial limitatios ad a clear uderstadig of the goals of admissio assists this. Recovery ca mea a wide rage of thigs to idividuals at this stage ad ofte requires subtle ad careful coversatios to establish expectatios. Ipatiet admissios geerally eed to address the followig key factors that prevet the perso receivig commuity-based care: a breakdow of care, a acute worseig of what was a stable coditio, a acute icrease i risk, or a plaed chage i treatmet that itself causes risk. As a compassioate healthcare professioal, it is temptig to wat to provide therapy for the uderlyig causes ad difficulties, but this ca be a risky path to tread if you are ot able to provide a smooth trasitio ad sustai the therapeutic work oce the perso is discharged. With limited psychology resource, it may be better to hold therapy i mid for a later date. These decisios should all be iformed by your formulatio, but a priority is ofte to cosider what will eable the patiet to safely receive future care i a commuity settig. Nevertheless, there are brief models of psychological therapy that may cotribute to readiess for discharge ad, i some circumstaces, therapy is a ecessary precursor to safe ad successful discharge. Durig the cosultatio for this documet, solutio focused therapy ad experietial dyamic psychotherapy were reported as particularly useful. Further iformatio o 16

21 specific itervetios ca be foud i the web resource that accompaies this documet. Not all itervetios eed to be delivered directly by the psychologist but the evidece suggests that psychology eeds to be a itegral part of a team to support the traiig ad cotiual delivery of itervetios that are evidece-based ad effective (Oyett, 2007; Murphy et al., 2013). I additio to formal therapy, psychologists i ipatiet services eed to be flexible about what they class as a psychological itervetio. This may for example ivolve: psychologists beig ivolved i care tasks to model iteractios ad commuicatio styles; focusig o the social relatioships o the uit; or thikig about the styles of commuicatio of staff. The psychologist eeds to have the cofidece to desig their itervetios aroud their formulatio of what the patiet ad service eeds most at that particular momet. Some itervetios may ot typically be thought of as a psychological skill, but if it is based o a psychological formulatio ad aimed at a relevat outcome the it is good psychology practice eve if that itervetio is as simple as doig a crossword with someoe. Traiig Oe area of psychological itervetio for which there is a huge existig evidece base is the positive effect of providig traiig to other staff. It is some years ow sice Moiz- Cooke ad colleagues (Moiz-Cook et al.,1998) first bega writig about the impact of staff traiig programmes o staff morale ad the cofidece of staff to be resposive ad iovative about how they maage their patiets eeds. There is ow a whole raft of literature demostratig that good quality of care is associated with staff cofidece, good leadership, good team workig, permissio to iovate, ad a focus o egagemet with patiets rather tha gettig tasks doe. Traiig has a sigificat role to play i supportig the developmet of these situatioal factors ad there are multiple examples of traiig programmes implemeted by psychology, which have supported staff to deliver good care (e.g. Barto & Williamso, 2011; Dexter-Smith et al., 2010; Petty et al., 2014). Ward staff ofte strogly welcome these traiig opportuities ad services may additioally have adopted quality idicators i staff traiig (e.g. recovery awareess) that psychology is well placed to deliver. Psychologists ofte have specialist kowledge i areas such as demetia ad ca develop ad deliver traiig with other agecies ad professioals. Traiig may focus o specific cliical presetatios (e.g. behaviour that staff fid challegig, relatioal difficulties), skills (e.g. cogitive screeig tools), therapeutic relatioships (e.g. commuicatio ad maagig relatioal dyamics) or specific approaches (e.g. midfuless, distress tolerace). Such traiig will always be more effective whe delivered as part of a overall leadership strategy o skills developmet ad supported by a process of o-goig supervisio, cosultatio, ad reewal. Summary The potetial for, ad beefits of, psychological work i ipatiet settigs are vast; for patiets ad their families, staff teams, services ad orgaisatios as well as idividual psychologists. The psychology iput eeds to be drive by compassio ad attetio to helpig others cotai ad tolerate ucomfortable emotios. To maximise the impact of psychology, the focus at ay poit i time eeds to be thought about carefully ad egoti- 17

22 ated with those who have ivested i esurig that a psychology resource is available. Kathry Dykes, Clare Hilto & Kate Ross Refereces Barto, K. & Williamso, J. (2011). Psychological formulatio as a basis for chagig ipatiet staff uderstadig of psychosis. PSIGE Newsletter, 117, British Psychological Society (2001). Workig i teams. A report by the Divisio of Cliical Psychology. Leicester. College Cetre for Quality Improvemet (CCQI; 2017). Stadards for ipatiet older adults metal health services: Fourth editio. Lodo: Royal College of Psychiatrists. Dexter-Smith, S. (2010). Itegratig psychological formulatios ito older people s services three years o (Part 1): PSIGE Newsletter, 112, Dexter-Smith, S., Hopper, S. & Sharpe, P. (2010). Itegratig psychological formulatios ito older people s services three years o (Part 2): Evaluatio of the formulatio traiig programme. PSIGE Newsletter, 112, Dexter-Smith, S., Oddy, J. & Cate, T. (2015). Leadership profiles for applied psychologists: Mappig the leadership academy s healthcare leadership model. Cliical Psychology Forum, 276, 4 5. Also at Firth-Cozes, J. & Corwell, J. (2009). The poit of care. Eablig compassioate care i acute hospital settigs. Lodo: The Kig s Fud. James, I.A., Clifford, M. & Mackezie, A.L. (2010). Traiee guidace o the use of case formulatios with older people. PSIGE Newsletter, 112, Kösters, M., Burligame, G.M., Nachtigall, C. & Strauss, B. (2006). A meta-aalytic review of the effectiveess of ipatiet group psychotherapy. Group Dyamics: Theory, Research, ad Practice, 10(2), Moiz-Cook, E., Agar, S., Silver, M. et al. (1998). Ca staff traiig reduce behavioural problems i residetial care for the elderly metally ill? Iteratioal Joural of Geriatric Psychiatry, (13), 3, Murphy, N., Vidge, A., Sadford, C. & Oyett, S. (2013), Cliical psychologists workig i crisis resolutio ad home treatmet teams: A grouded theory exploratio. The Joural of Metal Health Traiig, Educatio ad Practice, 8(4), Oyett, S. (2007). New ways of workig for applied psychologists i health ad social care: Workig psychologically i teams. Leicester: The British Psychological Society. Petty, S., Joes, L. & Aesley, P. (2014). Research update oe: Cogitive aalytic therapy ad a specialist metal health service for older adults: Relatioship-cetred care. FPOP Newsletter 126,

23 Chapter 2: The patiet jourey A psychological examiatio of the steps ad trasitios The patiet s jourey started well before they arrived i the ward. Uderstadig the traumatic evets ad disrupted attachmets, social circumstaces ad physical health chages that may have precipitated a admissio ca iform the psychological approaches eeded to facilitate the service beig experieced as a secure base. While services ofte speak about care pathways (i.e. procedures ad processes), this chapter cosiders the actual jourey of the patiet. This may have may stages ad may shift betwee the volutary ad ivolutary phases ad physical, cogitive, or fuctioal metal health eeds. There are key tasks that are fudametal to achievig good psychological care which iclude; debriefig the process of admissio, makig the perso welcome, agreeig the purpose of the admissio, commuicatig the legth ad structure of the ipatiet jourey, plaig for recovery, ad creatig a safe edig. Although the service expectatio may be that there is a clear route from begiig to the ed of the admissio, the road to be travelled is ofte far from clear to the patiet ad their family. This chapter 19

24 cosiders the trasitioal stages of that jourey from trauma ad attachmet perspectives ad, where appropriate, other psychological models. It is importat to remember that, for people with cogitive problems, the very task of holdig a itegrated jourey i mid may be problematic. Uderstadig of ad choices about potetial future steps, coheret arratives about what has goe before ad uderstadig what is happeig i the momet may all be experieced as cofusig, fragmeted ad ofte cotradictory. Extra cosideratio will eed to be give to how to capture the jourey i a way that the perso ca egage with, either by creatig a accout they ca access themselves, or by ivestig aother perso with the role of holdig a coheret accout of the patiet s experieces i mid. The experiece of arrival The process of admissio ca have a sigificat impact o the perso s overall experiece ad recovery. Ideally, the ipatiet eviromet is see as a place of sactuary where a perso ca recover from the buffetig forces they have bee exposed to ad have time to reflect ad recuperate. A plaed admissio may make this more likely. Icreased sese of cotrol, collaborative decisio-makig ad the ability to pla for brigig trasitioal objects are all more likely. Staff are also likely to be better prepared, thereby icreasig the opportuity for establishig a safe attachmet framework early o. Crisis admissios ca be more challegig ad may themselves be a source of psychological trauma. The level to which the patiet uderstads or feels i cotrol of the decisio to admit is particularly, although ot exclusively, challeged whe the admissio occurs as a result of the implemetatio of Metal Health legislatio. Such a rapid respose ca lead to loss of coectio ad extra attetio eeds to be paid by the team to geerate a sese of security. The team also eeds to work harder to build up a picture of the perso s idetity ad history beyod the labels ad descriptio of the crisis situatio. Alteratively, the jourey may start with a medical admissio ito acute services before evetual trasfer ito metal health/demetia services. These teams may have worked very differetly to your team ad the patiet may eed support to adapt to this. Repeated moves affect the perso s sese of safety ad belogig ad repeats the possibility for their behaviours to be misattributed, leavig the perso disorieted ad misuderstood ad experiecig a impersoal service from which it is difficult to build trust, as the commet below illustrates. I had to go to A&E after a fall, I had bee waitig three hours ad they decided I may have broke a hip. My husbad wet to move the car ad I was axious he was leavig, he asked them ot to move me till he was back but they did. I did t have my phoe o me, I did t kow where I was beig moved to, I did t kow if he d fid me. That shaped the rest of my experiece i hospital ad ow I m reluctat to atted at all. Patiets commoly report experiecig fear o first arrival; of their ow iteral state, of the type of service they expect to receive ad of the other patiets. The iitial impressio 20

25 made by the service (by the ature of the admissio process, the warmth of the welcome, the attetio to orietatio to the uit, cotaimet of iitial fears ad the establishmet of shared expectatios) has a lastig impact o the relatioship betwee patiets, families, staff ad the service. The process of therapeutic egagemet ad the laguage used for differet coversatios is covered i later chapters but there is a critical role for psychology i helpig the service to be midful about the importace of this iitial trasitio. The level to which the establishmet of iitial goals ad tasks are egotiated ad commuicated i a perso-cetred way ad the care with which the service model is explaied, sets the toe for the rest of the admissio. Key tasks durig a stay o a ipatiet uit Coectig It is importat to thik about psychological models that ca helpfully support the patiet ad team to thik about the focus of a admissio that goes beyod symptom reductio. For example, attachmet theory ca help our uderstadig of patiets experieces ad presetatio. Attachmet behaviours are especially evidet i times of distress, ill health or loss ad become more frequet with ageig (Browe & Shlosberg, 2006) as the perso tries to fid a way of soothig themselves based o their ow learig history. At differet times ad for differet people, this will iclude the full rage of isecure attachmet behaviours; aggressio, exteralisig of blame, detachmet ad avoidace of itimacy, passivity ad over-compliace, over-depedece ad so o. A compassioate ad therapeutic respose to these behaviours is more likely if the service uderstads the role of these behaviours i protectig the perso from further emotioal harm ad sees them as a expressio of the perso s isecurity ad distress. The ature of the relatioships developed o the ward (both with other patiets ad staff) has the potetial to become the basis for a further therapeutic relatioship o which sigificat recovery is built. Staff ca model ad assist patiets to develop psychological resources that will help them to recogise ad address their attachmet eeds ad develop more adaptive behaviours ad resposes. Goal settig A essetial compoet of achievig a recovery-focused ad patiet-cetred admissio is the early establishmet of goals that are based o the patiet s ow view of what a successful outcome would be. The visioig techiques of solutio-focused therapy led themselves to this ad ca help i shiftig focus from symptom reductio to a recovery orietated approach of hope ad optimism. From this stace collaborative goal settig ca aid idividuals to develop idiosycratic, meaigful, ad achievable goals. Acceptace ad Commitmet Therapy ca also be useful at this stage. Discussios might cover what would improve someoe s chaces of a valued (for them) future life, the role that perceptio of risk plays for differet people, what support is eeded to maitai importat relatioships, how readiess for discharge will be gauged ad by whom. Idetifyig the road to recovery There is a growig weight of good quality cliical evidece relatig to metal health recovery (see, e.g. Leamy et al., 2011) so this sectio focuses o the psychological processes of 21

26 egagig i oe s ow recovery. Oe approach to orgaisig the key tasks of recovery is to look at how to address the uiversal huma eeds that become more evidet durig times of distress. Kitwood (2010) defies these as Idetity, Attachmet, Competece, Comfort, Iclusio ad Hope. The patter ad itesity of eed demostrated i each of these areas varies accordig to persoality ad cogitive impairmet (Miese, 1992). Recovery may be see as establishig or re-establishig the fulfilmet of each of these eeds: Maitaiig or re-establishig idetity A perso may defie their idetity i multiple ways (category membership, social role, family ad occupatioal positio, etc.) ad the task i ipatiet services is to eable the perso to regai or assert a chose idetity that ehaces their sese of self ad self-efficacy. The perso eeds to be truly see. The team eeds to kow what is importat to the perso i order to provide a safe space, where the perso feels wated ad welcome to express themselves rather tha feelig suppressed by a domiat arrative. While formal documets ca be a useful startig poit to fid out factual details, more idiosycratic iformatio eeds to be gathered i order to ascertai the psychological traits of the idividual. Superstitios (Moiz-Cook et al., 2001), habits ad routies, as well as skeletos i the cupboard, eed to be cosidered alogside attachmet relatioships ad trauma. Self-positioig i terms of race, sexuality, geder, disability etc., are all importat here alogside what the perso makes of beig admitted to a place which may be defied by the age of its occupats. The experiece of receivig a diagosis ca impact positively or egatively o previously established roles ad idetities. Health psychology models of the process of adjustig to a ew diagosis ad forgig a ew idetity that assimilates the ew iformatio are of relevace here (Stato et al., 2007). Advocates, formal or iformal, may have a importat role i eablig the perso to sustai a idetity that is ot domiated by beig positioed as a patiet. Where admissio is experieced as a hadig over of cotrol, (either volutarily, coerced or forced), models of locus of cotrol are a useful framework for cosiderig i what way the perso s curret psychological positio is differet to their usual or desired state ad for moitorig a gradual retur to self-determiatio. People who have bee formally detaied have ecessarily had a level of cotrol removed from them, although i the best case sceario this ca come to be see as a carig step that promotes their move towards a more self-directed life. Eve for iformal patiets, there is a tedecy to assume that the service has more cotrollig power tha it actually does ad it ca be useful to facilitate both staff ad patiets to examie their uderlyig assumptios about whose role it is to make decisios. Critically, a more iteral style of attributio is usually associated with better metal health outcomes, so specific attetio to how a perso s self-determiatio ca be ehaced ad promoted is a importat aspect of recovery. There is likely to be a gradual process of trasitio of cotrol betwee the team ad the patiet ad the appropriate level of care ad itervetio eeds costat ad explicit review. The experiece of eedig others to step i ad assume cotrol of your decisio-makig ca be a major 22

27 challege to a perso s adulthood. Not beig ivolved i care decisios, perceivig care as meaigless or poor quality, ad believig oeself to be a iferior kid of huma beig ca all result from this dyamic (Olofsso & Jacobsso, 2001). Both trasactioal theory ad the reciprocal roles of CAT ca provide a framework for discussig the types of relatioship the team wat to adopt. Maitaiig ad establishig attachmet Admissio ofte leads to a disruptio of attachmet relatioships for patiets ad relatives ad frieds ad ca be experieced as sigificat loss, separatio axiety or existetial fear of abadomet. However, ot all relatioships are urturig ad safe ad, for some, the ward ca be experieced as a safe space. Both advocates ad the perso s key worker/amed urse ca be useful trasitioal guides who help people to feel they are ot o the jourey aloe. The presece of familiar objects ad the maiteace of usual habits ad routies may also serve to coect people to their ormal lives. Whe people eter existetial crisis, their eed for reassurace ca be overwhelmig ad the team may eed support to cosider how this ca be met i a cotaied way ad ot to repeatedly reject advaces ad attempts to be cotaied. Stable attachmets are a major protective ifluece i metal health ad cosideratio of how the perso s ormal attachmets will be maitaied ad supported eeds to be part of the assessmet ad formulatio process. Coectedess to family ad frieds, to oe s ow life, ad to the local commuity is a fudametal right ad eed, ad it is importat to foster creativity ad flexibility aroud how these are achieved. Imagiative ad proactive use of a rage of techology ca support people s ability to remai coected outside the hospital. The establishmet of relatioships with commuity metal health staff ad the commecemet of participatio i supportive commuity activities ca avoid further experiece of separatio ad loss whe the trasitio back ito the commuity is made. I was admitted ito hospital. I was i there for six weeks. I very rarely go aywhere without my wife, so ot havig her here i a ufamiliar eviromet was really difficult for me. My wife suggested that I call her at ay time ad that would be my lik. I was to ask the staff to help me use my phoe. Every time I did, they would tell me they could t ad that I should t be usig my phoe o the ward. I would the get up, get lost, tryig to fid someoe to help. Re-establishig a sese of competece Beig admitted to a ipatiet uit ca compoud the impact of ageig ad lifespa trasitios o the acquisitio ad itegratio of developmetal competecies. I the cotext of acute ill-health, there is usually a temporary iterruptio i the perso s typical level of competecy, which risks havig a log-term impact o their capacity for future level of fuctioig, if previously practiced skills are lost. Patiets may also arrive i metal health facilities with the expectatio that beig i hospital meas beig cared for, ad the team may eed support to recogise ad be explicit about the importat fuctio of activity ad ivolvemet i recovery. Meaigful occupatio that ehaces idetity ad wellbeig, activities that reiforce a sese 23

28 of competece, opportuities to demostrate idividual areas of competece, ad support to maitai, develop ad rekidle life skills should be a essetial elemet of a admissio. A particular role for psychology lies i makig sure that a assessmet of psychological competecies alogside strategies for ehacig ad developig these are part of the programme of skill developmet. This is likely to iclude strategies for self-soothig as well as relatioship competecies. It is difficult for a perso to retai a sese of competece whe they are ot fully iformed. A frequet complait from families ad patiets is that they do t kow what to expect, particularly i relatio to legth of admissio. It is commoly the case that services coceptualise distict phases of admissio; e.g. assessmet, itervetio, idetificatio of future care eeds, hadover, discharge but this may ot match the patiet s experiece ad expectatios. Oe source of psychological competece is the social roles a perso ormally ihabits; husbad, gradmother, cofidate, etc. Sometimes a break from some of these roles may be therapeutic but this is ot ecessarily the case ad beig facilitated to step ito role from time to time i a cotaied way may sigificatly ehace a perso s self-esteem. People may eed particular help to thik about how to stay i role i their relatioships with youg childre i their family ad how to explai the situatio ad safeguard the wellbeig of childre i a ipatiet eviromet. Re-establishig a sese of comfort The sese of psychological comfort ad iteral wellbeig ca be a helpful balace to the assumptio that level of symptoms idicates level of distress or dysfuctioality. This is also i lie with a recovery focused philosophy of metal health care where quality of life rather tha cure from symptoms of disease is the desired outcome. Models like ACT ad DBT may be particularly useful here. Oe model that is especially useful for helpig the team to thik about the ecessary requisites for psychological wellbeig is Maslow s hierarchy of eed (Maslow & Lewis, 1987). It is a model that will be very familiar to most of the health care professioals i the team ad may map well oto the phases of a perso s recovery the eed to re-establish safety ad get basic physical requiremets met, the key work of developig purpose ad belogig, the imagied future goal of achievig idividual potetial for a satisfyig life, as log as the model is ot iterpreted i a overly simplistic liear fashio. The impact o overall wellbeig of small discomforts ad icoveieces (faulty hearig aids etc.) ad of missig ay of these elemets are importat elemets of psychological comfort. Oe aspect of commual livig that patiets cosistetly report as udermiig to their wellbeig is the behaviour of others; either because it is experieced as distressig or threateig or because it disturbs the patiet s sleep or traquility. Staff teams equally report strugglig to kow how to maitai overall therapeutic ambiece whe there is a lot of oise, distress or disruptio. The impact of livig i close proximity to others is, to a degree, uavoidable but there is a wealth of literature o the desig ad use of the built eviromet that ca help to make the 24

29 case for specific evirometal itervetios (e.g. Day et al., 2000) ad psychology ca model debriefig as a importat part of helpig patiets to process ay fears they may have experieced. A sese of digity ad a eed for persoal privacy is a importat aspect of comfort that ca be difficult to maitai whe the perso eeds a lot of support with persoal care. This is particularly true for people with severe cogitive impairmet who may misiterpret the motivatio of staff who seem to be itrusively iterferig with their perso. Specific traiig for staff i approaches to persoal care that miimise distress has measurable beefit for both the patiet s wellbeig ad staff cofidece i their practice (Moiz-Cook et al., 2000; Ross, 2012). Maitaiig ad promotig iclusio It is essetial to recovery-focused care that people be ivolved i desigig their ow recovery ad psychology ca help the staff team to look at how the processes that are used i care plaig ad care review facilitate or hider the patiet voice beig heard. For a commetary o the extesio of iclusio to citizeship ad the promotio of disadvataged social groups, see Bartlett ad O Coor (2007). The overall culture of iclusio withi the orgaisatio will ievitably filter through to how the patiet experieces their ow presece i the service. Recovery colleges, lived experiece cosultats who visit the ward, ivitatios to participate i the processes ad structures of the orgaisatio, all speak volumes about whether the patiet is see as a parter i care or a passive recipiet. Ay approach that blurs the boudaries or reduces the social distace betwee them ad us, icreases the sese of iclusio. The visibility of older people who are ipatiets ca be ehaced by takig opportuities to facilitate access to evets that are site-depedet (research semiars, carol cocerts, ope days, etc.). It is ot uusual for smaller social groups to emerge withi the overall commuity i the ward. Establishig closer, more itimate relatioships ad friedships ca be a importat step to recovery for those icluded i them, but also carry the risk of psychological harm for those who are excluded from them ad those who are i a subserviet role i the group. Psychology is well-placed to help the team assess the health of ward relatioships ad to advise o facilitatig ehaced commuicatio ad iclusio strategies for those whose cogitive difficulties or cultural differeces prove a barrier to commuicatio. Re-establishig hope (love) Kitwood defies the fial all-ecompassig huma eed as love ad it is fudametal to recovery that a perso ca retai or establish a love of their ow life, somethig which we have iterpreted as hope. Value-based livig, solutio-focused care plaig, ad support to develop a idividual defiitio of what recovery meas all have a role i supportig a hopeful visio of a future life that is worth livig ad older people seem to respod particularly well to this type of approach (Eifert & Forsyth, 2005; Weatherall et al., 2015). 25

30 However, older people, families ad staff may hold age-related biases that ca impact o a idividual s hope for recovery. Recogisig these ad supportig alterative otios that chage ad adaptatio are possible ad eve commo i older age, is a major task for all ivolved. Offerig a opportuity for staff to discuss ad reflect o their ow experieces, reactios, ad values will esure these perceptios are ackowledged, validated ad challeged. Schwartz rouds, Balit groups ad peer supervisio provide aveues to explore these experieces. Attetio to hopefuless ad psychological comfort i staff also promotes the team s ability to ispire hope i others (Brooker, 2007). Oe source of hopefuless that is oly begiig to be tapped is the ecouragemet that comes from sharig i ad obtaiig ecouragemet from the experieces of others. Oe way of achievig this is to ask people to leave messages ad tips for future patiets whe they are discharged. Movig o The last step i the jourey through admissio ca be as complex as the first ad the attachmet issues ad eed for persoal autoomy are just as acute. For some, beig discharged home has bee top of their ageda throughout the admissio but eve so, this is a trasitio to be carefully maaged. Relatioships ad roles will have subtly chaged durig the period of admissio. Patiets ad families ca beefit from trial periods of leave ad the opportuities to talk through their iitial plas for the first few days at home. The adjustmet to beig at home agai ca be complicated by a total chage i the care team ad it is helpful to cosider how hadover arragemets betwee ipatiet ad commuity services ca facilitate a gradual reliquishig ad reformig of relatioships. The decisio about whe is the right time for someoe to leave the ward eeds to be based o clear criteria that reflect the perso s recovery jourey. Services uder pressure may struggle to be as cliet-cetred as they would wish to be i egotiatig the timig of discharge ad the flexibility of this trasitio. This is particularly likely to be the case whe discharge is delayed for o-cliical reasos. The psychologist ca help to articulate the potetial for relapse ad harm where this trasitio is likely to be challegig. A uilateral decisio to discharge ca leave the patiet feelig without cotrol which may well reflect their experieces of admissio. Care eeds to be take to esure the experiece is ot ivalidatig ad upredictable. Loss of cotrol ca be experieced by all whe a plaed discharge is stalled due to the absece of commuity resources. Both staff, patiets ad family may eed help to idetify how this period of waitig ca be used so that the perso ca cotiue the jourey to recovery. I wet to the MDT meetig ad they said Mum is goig to be discharged. I did t realise that this was a decisio to be made o her or my behalf, without our cocers or worries beig heard. So, you paic ad you thik about how I m goig to cope, how Mum is goig to cope. Before Mum was eve discharged my axiety ad hers were sky high. This could ve bee hadled better to help me ad Mum uderstad this was the best decisio for her ad to support us with our worries. 26

31 The discharge trasitio is a particularly difficult oe to achieve well whe the perso is movig o to a ufamiliar place. This ca compoud the admissio experieces of havig bee moved aroud from place to place ad be experieced as rejectio whe the ward has come to be see as a place of safety. Comig to terms with givig up oe s home ca be a additioal loss that eeds to be addressed. Psychological itervetio may be ecessary to help people maitai some persoal autoomy ad deal with the axiety associated with movig ito care facilities. Opportuities for trial periods ad a gradual trasitio that icludes beig able to start to form ew relatioships before reliquishig the old oes, are eve more importat. Ivolvemet i the preparatio ad hadover of detailed care ad life story iformatio ca help the perso to feel that their idividuality is recogised. I was told I was bed blockig, so they would eed to move me ito a residetial care home that was 15 miles away from home. I felt like I had to agree because I felt so guilty that someoe else eeded my bed ad I was prevetig them gettig treatmet. Whe death is part of the patiet s jourey with us Although death is less commo i metal health settigs tha acute physical health settigs, it is ot a uusual occurrece. Whe the staff team feels cofidet i the care they have give ad have had opportuities to deliver compassioate ad thoughtful support to both patiet ad family, ad they i tur feel that they have bee helped to a good death, it ca be a positive experiece for all ivolved. Although our focus is typically o care that eables someoe to safely move back ito a commuity settig, it is importat that our expectatios of a typical patiet jourey do t blid us to the possibility that death ca be a outcome. This blidess ca prevet us from supportig patiets ad their families early eough for this to be helpful. Attetio to what is eeded to maitai the therapeutic coect betwee the staff team ad the family is particularly importat whe the death is sudde or uexpected ad it is importat to articulate the psychological eeds of all cocered to have time to achieve this followig the death. Whe faced with a termially ill patiet, it ca be temptig to focus o the practical jobs to be doe i a attempt to provide some sese of cotrol but as Paye et al., (2008) reflect, death is as much a social process of lettig go as a biological trasitio. That social process will ievitably reflect the perso s curret ad previous relatioships, ad psychologists have much to offer i makig sese of workig with this iformatio. Ad the authors poit out that the sheer upredictability of death ca be difficult for the family members, ad the staff, to whom you offer support. This is what we specialise i beig able to tolerate ad help others tolerate ucertaity ad make persoal meaig out of complex ad chagig situatios. We are used to egagig i ucomfortable coversatios ad we ca support the perso ad their family to talk with each other ad the team, about what would make this period a more positive/acceptig time for all cocered, so that their death ca become a good edig. We ecourage you to read about the process of dyig ad what ca be expected you will be more able to have digified ad respectful coversatios if you are ot distracted by your ow axieties or lack of kowledge. Ad it seems obvious, but the impact of a death lasts log after the death has occurred ad staff (ad you) may eed emotioal ad practical support after the perso ad the family have left the ward. 27

32 The iformatio i the followig chapters of this guidace documet are all relevat to this stage of someoe s life: ask what laguage people use about death ad dyig (do t use euphemisms); be aware of the small psychological harms that ca damage this phase of the patiet s ad family s jourey; ote how the culture of the ward may get i the way of makig this experiece a positive oe (see chapter 6); use your skills to egage i a really huma way with all those ivolved i this process; get your ow support; be cofidet that you have somethig to offer; ad brig all your formulatio skills to bear, however iformally, o helpig people make sese of coflictig emotios. The family jourey The fact that their relative has bee admitted to hospital, meas that the relative is also i a process of trasitio. They are also o a jourey that i some ways will parallel the patiet s but i other ways will be uique. They may be goig through may coflictig experieces: comig to terms with ot beig able to cope as they had hoped; shame at the public itrusio of services ito a persoal situatio; relief at someoe else takig over the reis; grief at the loss of the other perso from their home eviromet; fear of the future, etc. He s beig cared for i hospital ad the I go home. People say ejoy the break which is extremely frustratig, as if I do t eed support to do this, I ca t ejoy the break I get loely, I ve lost my role for that period of time ad I do t trust he is gettig the same level of care or uderstadig that I offer whilst there. The patiet s capacity ad decisios about how they wat their family to be ivolved i their care, ca create complex situatios. Careful cosideratio ad uderstadig will eable you to support the differet idividuals affected by the admissio ad help them prepare for discharge. As with ay relatioship, uderstadig what meaig each perso is makig of the situatio is crucial just uderstadig each other ca ease may of the potetial struggles. Teams ca fid it particularly difficult to kow how to maage a situatio whe relatives disagree with each other regardig the care the patiet receives. They ofte welcome help to egotiate with the patiet ad their family how their ivolvemet is most therapeutic for everyoe. You ca also offer clarity of thikig about what is appropriate for the service to offer to the relatives, how the service ca egage meaigfully ad compassioately with family complaits, ad at what poit the relatives require support ad iput i their ow right. Whe a perso livig with demetia or i a acute period of distress are admitted to hospital, they may well struggle to commuicate their eeds with ew people i a ew eviromet. Families are vital sources of iformatio i most cases ad have a powerful story to share. They are ofte crucial facilitators i helpig the patiet to make their ow story heard. I terms of the support that the family eeds, ipatiet staff should ot assume that this has bee explored ad offered i the commuity. For may reasos, the poit of admissio might be the first time that someoe has had the opportuity or desire to talk to staff about what they eed, how they make persoal sese of the situatio ad their worries ad 28

33 cocers for the (potetial) future/s for them ad the patiet. Psychologists ca have a key role i makig this part of the family jourey a meaigful experiece ad oe that has lastig impact beyod the period of admissio. Families otice boards, iformatio booklets, videos about the ward, specific staff who work to support relatives, visitors bedrooms, drop-i sessios, recliig beds, ope visitig hours, ad shared activities were all cited as examples of wards tryig to fid ways of egagig with families. Relatives ca feel as disorieted as patiets to the culture, processes ad uwritte rules of the service ad may make iaccurate assumptios. The complexity of the orgaisatioal iformatio that families may have to assimilate about the differet roles of all the statutory orgaisatios ca easily overwhelm. Families too require a guide to get them through this jourey. Workig closely with commuity services ad third sector agecies is ofte vital i makig the may trasitios safe for everyoe. Predictable, regular commuicatio with a idetified family member ca ofte prevet may of the problems that ca arise whe people are frighteed, frustrated, ad feel isolated from what is happeig ad out of cotrol. Thikig through some of the cultural assumptios i your service (chapter 6) that create uecessary barriers to collaboratio is importat. It is also importat to be able to see the relative as a idividual with their ow uique rage of expectatios ad resources. Not all people are cofidet or competet or wat to be described as ad take o the roles of a carer. The service ca do families ad relatioships harm by assumig that ayoe with a family member therefore has a carer. The patiet will also have a view o the degree to which they see differet people as beig i a carig relatioship with them. Frieds may be iappropriately excluded from major decisio-makig whe they would be the perso the patiet would most like to ivolve. From visitig for tea, to helpig to pla care, you ca help the ward be flexible i facilitatig patiets ad relatives to opt i ad out, thus maitaiig a complexity of relatioship etworks that allow differet people to help i differet ways ad for the teams to welcome these iputs. Summary The experiece of the jourey through admissio is iflueced by multiple psychological factors. Throughout the patiet s jourey, professioals eed to esure that all people travellig with them feel coected, are kow ad ivolved at all stages. With iput from Nicola Gaw, DCP Faculty, ad Hayley Horto, Alzheimer Society, providig quotes collected from focus groups with patiets. Carolie Lamers, Ruth Watso, Nicola Robiso & Kate Ross Refereces Bartlett, R. & O Coor, D. (2007). From persohood to citizeship: Broadeig the les for demetia practice ad research. Joural of Agig Studies, 21(2), Brooker, D. (2007). Perso-cetred demetia care. Makig services better. Lodo: Jessica Kigsley Publishers. 29

34 Browe, C.J. & Shlosberg, E (2006). Attachmet theory, ageig ad demetia: A review of the literature. Agig ad Metal Health, 10(2), Day, K., Carreo, D. & Stump, C. (2000). The therapeutic desig of eviromets for people with demetia: A review of the empirical research. The Gerotologist, 40(4), Eifert, G.H. & Forsyth, J.P. (2005). Acceptace ad commitmet therapy for axiety disorders: A practitioer s treatmet guide to usig midfuless, acceptace, ad values-based behavior chage. Oaklad, CA: New Harbiger Publicatios. Kitwood, T. (2010). The experiece of demetia. Agig ad Metal Health, 1, Leamy, M., Bird, V., Le Boutillier, C., Williams, J. & Slade, M. (2011). Coceptual framework for persoal recovery i metal health: Systematic review ad arrative sythesis. The British Joural of Psychiatry, 199(6), Maslow, A. & Lewis, K.J. (1987), Maslow s hierarchy of eeds. Saleger Icorporated, p.14. Miese, B.M.L. (1992). Attachmet theory ad demetia. I G.M.M. Joes & B.M.L. Miese (Eds.) Caregivig i demetia. Lodo: Routledge. Moiz-Cook, E., Woods, R. & Gardier, E. (2000), Staff factors associated with perceptio of behaviour as challegig i residetial ad ursig homes. Agig & Metal Health, 4(1), Moiz-Cook, E., Woods, R. & Richards, K. (2001). Fuctioal aalysis of challegig behaviour i demetia: The role of superstitio. Iteratioal Joural of Geriatric Psychiatry, 16, Olofsso, B. & Jacobsso, L. (2001) A plea for respect: Ivolutarily hospitalized psychiatric patiets arratives about beig subjected to coercio. Joural of Psychiatric ad Metal Health Nursig, 8(4), Paye, S., Froggatt, K. & Hockley, J. (2008). Digity o the ward. Dyig: A guide for hospital staff. Lacaster: Help the Aged, i associatio with Royal College of Nursig. Ross (2012). Reducig distress ad aggressio i people with demetia, available i the web resource that accompaies this documet. Stato, A.L., Reveso, T.A. & Tee, H. (2007). Health psychology: Psychological adjustmet to chroic disease. Aual Review of Psychology, 58, Wetherell, J.L., Petkus, A.J., Aloso Feradez, M. et al. (2015). Age moderates respose to acceptace ad commitmet therapy vs. cogitive behavioral therapy for chroic pai. Iteratioal Joural of Geriatric Psychiatry. 30

35 Chapter 3: Therapeutic egagemet The purpose of this chapter is to address those issues which are specific to the quality of the relatioship the psychologist has with differet elemets of the service (idividual patiets, staff teams, etc). Therapeutic egagemet is a fudametal pre-requisite for effective cliical workig but ca take differet forms ad serve differet purposes. Pereira & Woollasto (2007) defie therapeutic egagemet as spedig quality time with patiets ad aims to empower the patiet to actively participate i their care. Cliical psychologists workig o ipatiet uits may be workig directly with patiets ad also with the staff group. So, we may exted this defiitio to spedig productive time with ward staff ad supportig them i the psychological aspects of their care work. This chapter focuses o those factors i the relatioships withi the ward that are likely to cotribute to the perceptio of a good egagemet ad outcome across differet stakeholders. This may, at times, require us to challege beliefs about the aim ad purpose of a ipatiet admissio ad the proposed measures of successful outcome. Workig therapeutically i a ipatiet settig with older people presets uique challeges. These are the most seriously distressed of the older populatio whose care caot safely be maaged at home; ofte with sigificat pre-existig physical health coditios, sesory ad/or cogitive impairmets, may of whom live withi a exteral carig eviromet of family/spouse or care home. I additio the multidiscipliary team may ot have had a psychologist o their team before. It is importat to be very clear to patiets, family members, the ipatiet staff team ad maagers about what we ca offer ad it is importat to bear i mid that the etire time a psychologist speds o the ward is a opportuity for sharig kowledge, modellig ad therapeutic egagemet. This time also allows for psychologists to lear about the roles, tasks ad skills of, as well as the dilemmas ecoutered by, the ipatiet team. 31

36 Egagig the idividual The task of egagig with a patiet may vary from the relatively straightforward whe the perso has good isight ad is ready for chage, to the more complex whe the perso s emotioal state makes effective egagemet difficult to achieve or whe their laguage skills are such that uderstadig or makig their ideas uderstood has become complex. It is always importat to establish the emotioal ad psychological sese they are makig of the situatio, their uderstadig of their distress, their perceptio of why they are i hospital ad what, if ay, are their goals for the admissio. This may be more complex tha a direct coversatio with the idividual ad require time ivested i e.g. observatio, coversatio with those who have kow/do kow the perso, ad a more detailed assessmet of their commuicatio strategies. Whether the perso is there volutarily or uder detetio is likely to impact greatly o their egagemet. I additio, some people may have o prior experiece of psychological thikig. This ca make it difficult for people to see the value of itervetios ad to take the potetially paiful risks of egagemet. There may well be practical barriers to egagemet, such as difficulty arragig private space, ad competig ward or visitig priorities. A further potetial complicatio comes from the amout of time that psychologists have dedicated to workig o the ward. There may be limited time for idividual therapeutic work ad you will eed to be careful ad explicit about what you are tryig to egage the perso ad the team i (see chapter 1). The priciples of good egagemet i ipatiet uits are: Respectig ad empowerig patiets; Beig available; Focusig o egagemet, ot just o tasks; Effective therapeutic work; Embracig chage. (Pereira & Woollasto, 2007) These are good priciples to follow but may eed adjustig whe patiets are highly emotioally distressed or cogitively impaired. For people who are presetig a high risk to themselves or others, the focus may ecessarily be o workig with staff to develop care plas which promote work related to safety ad stabilisatio, preparig the groud for therapy at a later stage ad potetially with aother team. Psychological formulatio ca be a key part of this work, as ca itroductory work o the recovery model ad helpig the perso to begi to make iitial sese of what has happeed (see chapter 4). Psychologically iformed assessmets of risk ad positive risk takig are also importat as is likig this to a coheret formulatio of the situatio ad the future (rather tha a stadaloe admiistrative exercise). Work o emotioal regulatio, rediscoverig copig strategies, ad solutio focused work o very short-term goals ca all be helpful i settig the scee for later more i-depth work with the perso ad/or the wider system i which they live. Egagig families ad other carers I ipatiet services it ca be easy to be lured ito workig with the people that we regularly see (patiets ad ipatiet team) ad ot give eough attetio to those from other teams or the perso s family. Whe the perso returs to the commuity, their relatio- 32

37 ships with others will ievitably have a impact o their metal health ad it is importat to actively egage with these sigificat others to discuss their role, if ay, i supportig the perso s wellbeig oce they leave the ipatiet service. See chapter 2 for cosideratio of the carer s jourey. There are specific challeges to egagemet for family members, particularly whe the family view ad staff view differs regardig where the problem lies or what is the ature of the difficulty. It is commoplace, for example, for relatives ad iformal carers of people with sigificat cogitive impairmet to have a limited or eve mistake uderstadig of the ature of that impairmet. Family ca beefit from the sese of cotaimet provided by the service, the offer of a framework to support their uderstadig, the safety of beig able to tolerate axiety ad complexity, ad the support that ca be provided by the team ad the eviromet. Psychologists ca have a key role i helpig the wider system/s develop a shared uderstadig (that tolerates multiple arratives) that is coheret eough for everyoe to fid some commo groud from which to move forward. Ofte models from core psychological uderstadig (e.g. social, cogitive, behavioural) ca be as, if ot more, helpful tha cliical models. They also provide a helpful ad ecessary bridge betwee welless ad illess ad offer support to all the idividuals withi the system whilst explicitly ormalisig distress ad offerig ways forward. Egagig the staff team There are two mai tasks required here, first showig a willigess ad desire to uderstad the team s experiece ad secod demostratig your reliability. To develop a uderstadig of their role ad the competig pressures they face we could shadow the team members ad observe what they do; show iterest ad cocer about their workig coditios, the stress they are uder ad highs ad lows of their work lives. Health care staff workig i acute settigs have bee subject to severe scrutiy ad criticism, placig accoutability at a idividual rather tha systemic level, beig told to put their patiets first (e.g. Borlad, 2012). Ipatiet teams, who may be lackig the ecessary capacity ad resources to coduct their work, ca experiece high level guidace as patroisig ad out of touch. I order to effectively egage with staff, psychologists eed to show a o-judgmetal approach that appreciates the huge systemic ad orgaisatioal pressures that may affect frot lie staff. Our basic cousellig, listeig ad empathy skills will be ivaluable here i buildig relatioships of trust ad respect. Demostratig reliability is achieved by persistece, by turig up regularly, ad by beig there for the team. Dedicatig regular slots so that idividuals ca be see at short otice ca help, both for staff ad patiets ad their families. These sessios eed to be flexible to allow for periods of acute distress or distractio whe the perso may ot be able to egage but these slots ca be used for cosultatio if ecessary or for spedig time demostratig a visibility o the ward. Take advatage of formal ad iformal opportuities to offer a psychological opiio, for example, cotributig to cliical meetigs ad offerig psychological formulatio of cases. Ipatiet teams may have little experiece or kowledge of psychological formulatio ad may ot always uderstad the value of psychological iput as part of a holistic approach to patiet care. Be patiet; buildig relatioships with teams takes time. The more 33

38 experiece staff have with psychologists the more they will value your iput ad you will become a essetial member of the team rather tha what may feel like a add-o i your first weeks or moths. Staff perceptios of a perso ad assumptios about their behaviour ca impact o egagemet sometimes very egatively; this might relate to e.g. assumptios about you as a psychologist, aother team member or a specific patiet (Hill, 2010). It is importat to be able to discuss these perceptios ad challege uhelpful assumptios i a safe space. Oe way of doig this could be to use the Dual model strategy approach from CBT (Wells, 1997) ad suggest that while team member A has oe idea about the cause of a certai behaviour (Theory A) the psychologist has aother idea (Theory B) ad how could we go about fidig out which is the most helpful i this situatio? Self-care for the psychologist As psychologists we hold o to hope ad maitai the effort, with sometimes very little feedback that egagemet is likely. Maitaiig our values of perso-cetred care is vital. Good professioal practice regular cliical supervisio, good cliical goverace, structured professioal developmet will all help to icrease your persoal ad professioal cofidece. Cotact with other psychology colleagues ad membership of professioal groups ad etworks is likely to play a importat part here, as is the support of people o the ward you eed to fid ways of feelig you belog to the service eve if that is oly i small part iitially. Ipatiet services ca be emotioally demadig for people of all professios ad takig time to reflect ad actively maage your ow stress will both protect you from burout ad model good self-care for others. The iitial approach Oe of the challeges to egagemet with staff teams could be the psychologist beig perceived as i a peripheral positio to the ward team ad this ca be a problem for both parties. Takig time to explai what a psychologist ca offer will be helpful. Actually demostratig the collegiate, cosultative approach that is typically used by psychologists rather tha just talkig about it may be required as it is, hopefully, differet from the rather traditioal, hierarchical style that is ofte commo i ipatiet services. A willigess to get ivolved i workig with the ward team ad ivitig the team to make suggestios of how you could cotribute to the team are useful iitial steps to egagemet. Demostratig the variety of what ca be offered, from debriefig or critical icidet support to facilitatig team away days, ca ecourage the team to uderstad how psychology ca make a differece. Developig agecy It is importat to ackowledge ad emphasise the vast reservoir of implicit kowledge held by the ward team. This is the itimate kowledge of idividual patiets, of patters of iteractio, ad of services that have bee built up over years i additio to their ow professioal traiig ad kowledge of evidece based practice. The uoticed professioal competece (Ahrekiel et al., 2013) may be poorly articulated (ad poorly valued by both the staff cocered ad exteral others) but oetheless is of great value i face to face 34

39 care. To build o this meas givig space to teams to express their accouts ad ackowledgig their arratives of successes achieved through their ow agecy. It is also importat to edorse more formally recogised skills ad kowledge ad, as appropriate, to defer to other advice. Therapeutic egagemet is ot just about helpig other people come roud to our viewpoit. Make sure that the egagemet is geuiely two-way. Showig respect for ward staff s kowledge ad skills will hopefully icrease their sese of agecy, of cofidece i their ow abilities ad go some way to ehacig their ability to be proactive i difficult situatios. Oe way of achievig this may be through offerig spaces i which teams are supported i explorig the learig possibilities from their daily experieces (formulatio, reflective groups, supervisio etc). These ca provide assurace to team members that they re o the right track, ad prevet them from feelig as though they re flouderig i cliical situatios. But do t forget the day to day small iteractios that facilitate egagemet withi a team. Although we are traied to provide formal itervetios ad be able to ame what we are providig, these other more immediate approaches take o more time out of your or their work day but ca build ito a geuiely egaged relatioship (see chapter 8 for some specific ideas i this area). It is possible to ehace teams existig sese of agecy by empowerig them with ew skills ad kowledge, ad especially by arragig opportuities for success. Teams ca be ecouraged to take a positive, solutio focused approach, to egage i collective edeavour ad to set themselves achievable goals (Jackso & McKergow 2007). Measurig chage will allow for lots of positive feedback to teams, ad to their maagers as appropriate. May ipatiet teams have a rage of therapeutic skills that are beig uderutilised ad it will be helpful to fid out about these skills ad to make use of them. This has to be doe i a careful maer to esure teams are ot delegated tasks they feel uprepared for. I geeral though, this ca be a very fruitful approach as egagig people i challegig ad meaigful work, ofte i this case the sort of work may have bee watig to do for a log time, ehaces their ier sese of motivatio ad egagemet at work. More straightforward skills teachig may be appropriate at times as log as the teachig is wated ad eeded by the service ad team members attedig uderstad why it is importat ad useful for them to give their time to the sessio. The process of helpig the team to idetify what its learig eeds are will likely be as, if ot more, importat tha the teachig itself. Make sure you also provide literature ad produce hadouts i key cliical areas, so that staff uable to atted sessios ca beefit from them or provide a aide memoire for times whe the psychologist is ot available. Ad make these iterestig to look at ot huge academic works but attractive ad iterestig visual formats that ispire people to egage with them. Hoour the meaig of the ward team s experiece A importat part of ay psychological therapist s relatioship with their cliet will be warmth, opeess ad o-judgemetal positive regard. The latter is particularly import- 35

40 at with the staff team as they typically have chroically low morale (e.g. Kleebauer, 2015) which may be partly due to their poit of view rarely beig ackowledged. Cliical psychologists are i a good positio to rectify this by usig iterpersoal skills they are well versed i. Uderstadig staff s lived experiece, their assumptios ad expectatios will help us i tailorig therapeutic programmes, ot oly to the idetified patiet, but also to the people who are usually goig to have to carry them out. Sometimes just beig there to liste ad validate team s tales of their difficulties at work is all that is required. No solutios are sought or are available, it is sufficiet for their arrative to be heard ad believed, ad this allows more positive work to be doe. Part of appreciatig the experiece of ipatiet teams is kowig that therapeutic tasks are oly oe of a umber of tasks that they will be called upo to do. However importat they may ackowledge this part of their role, staff will cotiue to have to atted to other demads, ad remaiig midful ad respectful of this will esure we do ot add to their feeligs of beig overwhelmed. I cosiderig the wider cotext of the work, it would be importat to develop a appreciatio of the possible issues the team might be facig, related to the maagerialisatio of the health service. For istace, there might be pressure to improve performace ad efficiecy (e.g. evideced by reduced legth of stay) i the cotext of static or shrikig budgets through local ad atioal budget tighteig (Csipke et al., 2016), impedig CQC, Metal Welfare Commissio, or RQIA ispectios. It may be appropriate to respod to the stress felt by the ward team by usig our positio to articulate the importace of self-care ad egotiate how this might be achieved through providig some cliical leadership i this area (BPS, 2011). Validatig outcomes Team expectatios about chage i the perso, their behaviour ad their capacity for chage, particularly i chroic coditios or demetia, will have a strog impact o therapeutic egagemet. It may be ecessary to try to combat therapeutic ihilism. I part, this ca be doe by validatig the challege of workig with older people as ipatiets. Helpig teams to cosider how they would kow that they are doig a good job ca be motivatig. It is importat for all of us to kow that our iput is havig a positive impact o those aroud us. Creativity with outcome may be importat ad may require you to actively idetify small chages very quickly rather tha waitig for obvious chage to become apparet. Specific ad perso-specific outcome measures could be itroduced for this e.g. time spet attedig to a coversatio, someoe flickig through a ewspaper or askig about a visitor. Or it may be sufficiet to highlight ad commed such small, but sigificat, positive outcomes ad hoc. By directig attetio to successes that the ward team have achieved, rather tha focusig o failures, mistakes or otherwise usatisfactory outcomes we ca ackowledge the value of the team s work. 36

41 Addressig potetial barriers ad flexibility The cotigecies of workig i a ipatiet service are very differet from workig i, for example, a commuity team. I ipatiet services there will be a large group of staff ivolved i shift workig. The practical cosequece of this is variable availability of staff eve for predictable regular evets. Cosequetly, psychologists may eed to be adaptable. We may eed to cosider variable times for meetigs, repeatig meetigs to reach larger umbers of staff, shorter meetigs ad postpoig meetigs at short otice with a fallback pla available for how to sped time o the ward. It could be helpful to allocate regular slots for idividuals to be see at short otice as required ad it probably wo t be possible or desirable to operate a referral ad waitig list system i such a eviromet. Bearig i mid the importace of therapeutic egagemet across the service will help you address potetial coflict i a helpful way. There are times whe it is etirely appropriate for psychology to questio or challege but it is importat that we get alogside ad demostrate that we value the people we work with. Egagig with the whole system There are likely to be multiple views held (by the patiet, staff teams, families, iformal ad professioal carers etc.) of the issues ad situatios which cotributed to the patiet s admissio. I cosiderig therapeutic egagemet, it is importat to brig these differet perspectives together ito a coheret arrative so that differeces of opiio ca be egaged with ad worked through. Usig a systemic approach ca be useful here (see Fredma & Rapaport, 2010 for a useful framework). Appreciative iquiry is aother stadardised framework for egagig across systems that has had good outcomes i ipatiet health services (Scerri et al., 2015). Summary Ackowledgig the impact o egagemet of the relatioships with ad betwee the differet elemets of the system i the ipatiet settig helps iform the ecessary coditios for chage, such as trust, agecy, empowermet ad reflexivity. Chapter 5 offers useful reflectio about the maer ad laguage you may use to egage with the systems ivolved ad chapter 6 offers a useful framework for thikig about orgaisatioal chage. However, sometimes, you may experiece others i your team as disegaged from or eve directly udermiig of what you are tryig to achieve. This will call for cosiderable resiliece ad self-awareess, a willigess to examie your ow role i cotributig to ay resistace, a objective aalysis of the competig demads ad pressures, ad a professioal awareess of what is ope to debate ad what crosses over ito poor patiet care or staff bullyig. Your relatioship with the operatioal team ad your professioal etworks will help to sustai a frak cosideratio of what actio it is sesible to take ad what goals you should set yourself i your egagemet with the service. Fraces Duffy, Tamsi Fryer & Paul Whitby 37

42 Refereces Ahrekiel, A., Schmidt, C., Stee Nielse, B., Sommer, F. & Warrig, N. (2013). Uoticed professioal competece i day care work. Nordic Joural of Workig Life Studies, 3(2), Borlad, S. (2012). Disbelief as urses have to be told to put patiets first: Staff remided to treat sick with love ad compassio. The Daily Mail. Retrieved 4 December 2012 from British Psychological Society (2011). Good practice guidelies o the use of psychological formulatio. Leicester: Author. Csipke, E., Williams, P., Rose, D. et al. (2016). Followig the Fracis report: Ivestigatig patiet experiece of metal health i-patiet care. British Joural of Psychiatry, 209(1), Fredma, G. & Rapaport, P. (2010). How do we begi. I G. Fredma, E. Adeso & J. Stott (Eds.) Beig with older people: A systemic approach. Lodo: Karac Books Ltd. Hill, T.E. (2010). How cliicias make (or avoid) moral judgmets of patiets: Implicatios of the evidece for relatioships ad research. Philosophy, Ethics, ad Humaities i Medicie, 5(11). Extracted from Jackso, P.Z. & McKergow, M. (2007) The solutios focus: Makig coachig ad chage SIMPLE (2d ed). Lodo: Nicholas Brealey Iteratioal. Kleebauer, A. (2015). RCN urges ew govermet to take actio o low staff morale. Nursig Stadard. 29 (36), 7 7. Pereira, S. & Woollasto, K. (2007). Therapeutic egagemet i acute psychiatric ipatiet services. Joural of Psychiatric Itesive Care, 3(01), Scerri, A., Ies, A. & Scerri, C. (2015). Discoverig what works well: Explorig quality demetia care i hospital wards usig a appreciative iquiry approach. Joural of Cliical Nursig, 24(13 14), Wells, A. (1997). Cogitive therapy for axiety disorders. Chichester: Joh Wiley & Sos. 38

43 Chapter 4: Psychological formulatio This chapter articulates how psychological formulatio ca be used to develop a shared uderstadig that supports a perso s recovery durig their ipatiet stay. For overarchig guidace o psychological formulatio, see Johstoe et al., (2011). What is a psychological formulatio? A psychological formulatio draws o psychological theory ad research to provide a framework for explaiig how a problem developed ad is beig maitaied. A formulatio is used to decostruct complexity, to prevet therapeutic drift (Dema, 1995) ad to improve outcome (Persos, 1991). Psychological formulatios are detailed explaatios of why this perso (or family or team or service) came to have difficulties at this time ad are the summatio ad itegratio of the kowledge which may ivolve psychological, social, biological ad systemic factors. It is essetially a series of theoretically drive ad testable hypotheses that helps orgaise ofte complex ad cotradictory iformatio about a perso. At its heart should be the voice of the idividual themselves. Natioal policy, e.g. the Natioal Service Framework for Older People (DoH, 2001), has 39

44 stressed the beefit of psychological formulatio i uderstadig the iterplay of physical, social ad metal health eeds preset i older people. Furthermore, the Royal College of Psychiatrists College Cetre for Quality Improvemet (CCQI, 2017) best practice stadards recogise the importace of formulatio ad recommed that psychologists have sufficiet time to provide them. Purpose You may be formulatig a idividual s presetatio ad care, levels of risk, the dyamics withi a team or a family, or how orgaisatioal, team ad idividual factors are playig out relatioally. The key is that you are articulatig ad brigig attetio to the psychological compoets of the situatio beig discussed. A psychological formulatio is developed where possible with the perso that it is about (or family or team or service) ad is cotiuously ope to revisio i light of experiece; feedback o the effectiveess of itervetios is evidece of how close the formulatio is to accurately explaiig the situatio. Formulatio s pricipal purpose, regardless of the model or the theoretical uderpiigs, is to help develop a shared uderstadig ad to select ad guide the cliical itervetios o offer (Johstoe & Dallos, 2013). I ipatiet services this is importat across the whole multidiscipliary team ad should aim to iform ad idividualise both the overall therapeutic itervetio strategy ad the day to day offer of ipatiet care. This chapter will discuss issues relatig to the breadth of formulatio (from idividual to orgaisatioal) although it is likely that the most commo format will be with a idividual or a care team ad about a idividual patiet. As a shared uderstadig is sought about ad with a patiet, it is also importat to thik carefully about who iformatio is shared with. Not everyoe eeds to kow everythig. There is a balace to be struck betwee sharig themes, risks ad implicatios with the people who eed to kow i order to work effectively with the perso, whilst also eablig the idividual to retai some privacy about thigs that they would prefer to keep to a more limited audiece. Teams ca obviously formulate without the patiet or family preset ad should always be formulatig their itervetios carefully. However, at some poit (ad this ca be i may creative ways), the perso themselves should be brought ito the process i order to develop a collaborative, shared uderstadig of the way forward. It ca be too easy to get swept alog i the sese of urgecy ad forget to meaigfully iclude the patiet, assess their capacity specifically i relatio to this process, ad discuss their thoughts about who should be brought ito the process (ad who should ot). The iclusio of the family ca be complex to thik through. It is ofte vital but the patiet s decisio about their ivolvemet is crucial uless they do ot have the capacity to decide; ad i this case the relevat processes eed to be goe through i order to make a iformed decisio about the appropriate course of actio. Beefits of formulatio ad reflectio o work Psychological formulatio has bee foud to be effective i three broad areas that are relevat to ipatiet care: 1. Shared recogitio ad icreased empathy for the perso (e.g. Keedy et al., 2003). 40

45 2. Ehacig the quality of the itervetios ad care plaig (e.g. Moore, 2007; Murphy et al., 2013). 3. Icreasig capacity withi the staff team for safe ukowig ad reflectio; the ability to tolerate a positio of ucertaity i regard to a patiet rather tha impose a framework or decisio that is iadequately developed (e.g. Scho, 1987). Before itroducig psychological formulatio ito a service you eed to be clear o the purpose of doig so ad how the impact will be measured (ad by whom). To reduce legth of stay? To obtai a better uderstadig of the perso ad their difficulties? To iform relatioships betwee the perso ad the team? To provide more focused itervetios? To improve the log-term prospects for recovery? There are also practical decisios such as: What are appropriate thigs to be shared e.g. with the patiet preset is probably ot the time for the team to be reflectig o their ow emotioal reactio. Make sure the purpose ad therefore cotet ad boudaries are clear from the start. Who will the formulatio be shared with/i what format? Whe will it be reviewed ad by whom? What level of detail will be etered i the perso s otes? How will coflictig opiios be articulated? How will the perso hold a copy safely (e.g. ot accessible to family if this is ot appropriate or wated)? Theoretical model, focus ad process It is easy to coflate the model, process ad cotet/focus of a formulatio but they all eed careful thought (see Table 1 for examples). The theoretical model that you choose eeds to be able to articulate the problems that are uder cosideratio, be accessible for everyoe ivolved, ad have a strog theoretical itegrity. You also eed to cosider whether you are goig to use oe theoretical model across situatios or use various models. As described above, the focus might be at a idividual, team or orgaisatioal level. The process might be with oe perso, i a group, aroud a table ad paper, up o a live scree etc. A umber of the services who demostrated examples of good practice durig the developmet of this documet use a overarchig formulatio model to guide the team case discussio i some way ad details of these ca be foud o the website. They all brig their ow dis/advatages so time spet thikig this through is worth the ivestmet. Figure 1 demostrates a formulatio of curret iteractio style from a itegrative perspective. Other more liear models led themselves more clearly to the process of plaig the steps of a perso s recovery, e.g. see Laidlaw et al. (2003) or James (2011). 41

46 Times of beig powerless. Irreversible chage to body, pai ad discomfort. Absece of alcohol ad drugs as umbig. Low tolerace of distress. Neglectig coditioally available. Uacceptable. Uable to preset OK versio of self. Low tolerace of distress. 1. Uable to maitai cotact with thoughts, feeligs, body ad eviromet. Dissociatio. Distractio (souds, pacig). 2. Shows ager towards others, projects ow difficulties oto others. Verbal aggressio ad physical aggressio towards others. We are held at a distace. We caot share her experieces. We are ot perceived as beig available. We feel hurt. We feel icompetet. We are less likely to persist with uderstadig her experiece. 3. Neglect of self, strivig to be the extreme of othig. Forcig others to demostrate care. We feel forced ito providig limited, coditioal care. We feel abusive. Figure 1: Example of a diagrammatic itegrative formulatio, drawig upo CAT for the mai structure. Regardless of the theoretical model you choose, it is importat to esure that ay formulatio i ipatiet services provides space for the followig: The perso s idetity beyod the presetig problem to be heard. The meaig of the curret situatio for them ad for others to be apparet. Iclusio of other problems that the perso is experiecig such as physical illess, housig problems, fiace, some of which may get lost with the immediacy of risky factors. A very clear lik to the itervetios/perso s ow strategies that will follow from the formulatio. Thigs move quickly o wards ad a well-meaig formulatio that was helpful i the momet ca rapidly get lost amogst other urget issues. A clear strategy for commuicatig this ew uderstadig to the people that were t i the room i a way that is respectful to the idividual ad helpful to those readig it. A uderstadig of whether there are people that wo t be give access to this formulatio iformatio ca be too easily see as available to all whe teams work this closely together. A pla for how it will be traslated ito the perso s care record. Do t assume that others will or ca do this, the detail of the wordig of a formulatio is ofte critical. Ad do t be afraid to be very specific about what you mea the itervetio to be followig a formulatio. Whe doe well, a care pla ca move from reflectig policy ad risk to reflectig the perso at the heart of the discussio (Hull et al., 2015). The impact of the team o a idividual s wellbeig. These are itese eviromets where small frictios ca have a sigificat impact. Use the formulatio sessio to 42

47 Table 1: Reflectig o the focus, aim ad examples of formulatio. Focus of formulatio The aim Examples Idividual formulatio More tha oe perso Systemic/orgaisatioal formulatio To esure the perso s voice is heard. To formulate the eeds of the idividual. To cosider the reciprocal relatioships betwee the patiet ad their immediate eviromet. To eable idividuals to make meaigful chages to their ow behaviour. Cosider accessig a advocate for people who are strugglig to make their views kow. Formulatig the eeds of the patiet withi their family or with the ipatiet team (America Psychological Associatio, 2014). To eable collaborative relatioships betwee idividuals ad key workig relatioships. To ifluece coditios that are coducive to chage for the patiet. To eable chage to occur withi relatioships. Formulatig the eeds of the team, the service ad the orgaisatio. I tur this will iform uderstadig of idividual eeds. To ifluece the coditios of workig ad resources available to eable the uit to provide therapeutic care. To miimise uhelpful patters of behaviour at all levels of the system. To ifluece trasitios of care. Uderstadig a presetig difficulty; cosiderig alterative uderstadigs to diagosis; providig a idividualised uderstadig of triggers ; to uderstad axieties or obstacles to chage withi the immediate care settig. People livig with demetia whose stress ad distress presets as resistace or aggressio; a perso who is experiecig high distress ad caot articulate this verbally. Meetigs with ursig team to use a uderstadig of a perso s attachmet style to pla a strategy for the delivery of ursig care. Meetigs with families to eable a clearer uderstadig of the family issues that are cotributig to the curret difficulties. Uderstadig your ow role ad approach withi the system; uderstadig how distress or difficulty has bee coceptualised withi the system; formulatig barriers to chage (Hickma & Crawford-Docherty, 2010); formulatig how the system is respodig to axiety. Workig o the relatioships betwee differet parts of the orgaisatio (ipatiets, commuity, safe-guardig, crisis) to improve the psychological quality of the whole care pathway. discuss these ad brig them out ito the ope so that you ca also pla a way of dealig with them. Difficulties that the team may experiece i processig ad respodig to the idividual patiet s presetatio of distress ad attachmet style. Remember that formulatio is iheretly a process ot a evet ad you have the ability o a ward to meet with people o a more ad hoc basis. Use that to your advatage to build up a arrative that works for everyoe ad with which everyoe is ivolved. The process does ot have to be the same for everyoe. For some people, meetig with their family member ad the amed urse will be very stressful but they will value the chace to share ideas. Others will ot wat to be i the room at all but will be happy to sed very strog messages via you o their behalf (ad wat to see a draft of the resultig formulatio as soo as the meetig is fiished). Ad some people will wat their whole team there i oe go. You should always be tetatively thikig about the meaig of each decisio for each perso ad tryig to 43

48 respectfully balace the eeds of all parties. Ultimately what you wat is ot the big meetig with all cocered, but a shared, theory drive ad persoalised arrative about what has happeed, ad what eeds to happe to move forward. Potetial problems ad ways to overcome them Facilitatig a psychological formulatio i this settig ca be complicated. A large umber of people are ivolved i a admissio but havig them all there with the idividual ad the family is rarely appropriate. It is importat to thik about who does (ot) have the right to be icluded i the iformatio gatherig ad sharig. Although the team do eed to be formulatig the perso s eeds ad their ow itervetios, the iclusio of other people such as family members eeds careful cosideratio, especially i light of capacity ad coset from the patiet. Whe formulatio takes place as a group discussio, the facilitator also eeds to be cofidet i dealig with multiple emotios i the momet (their ow icluded) as this is ofte the first time that idividual stories have bee reflected o ad shared. This may also be the case i the cotext of potetial recet traumatic experieces, recet discoveries of iformatio that challege established family stories ad disrupted attachmets. Research ito the impact of team/group psychological formulatio o the patiets ad carers that were ivolved made for some ucomfortable readig (Tarra-Joes et al., 2016). Whe it wet well the process was recovery orietated ad ispired hope, offered shared meaig for the first time, helped people see that there was a way out ad what they could do themselves. But there were istaces whe patiets ad carers reported that the meetigs perpetuated a authoritative ad powerful professioal team that they felt i battle with ad judged by. The factors that made the meetig more likely to be a positive experiece are a useful framework for ay meetig where patiets ad carers are ivolved ad worth bearig i mid ad sharig with colleagues as this is ofte the domiat way that teams egage with patiets: Make sure the room is cofidetial ad that there is a sig idicatig ot to be disturbed. If someoe does disturb you, be proactive i protectig the meetig. Toleratig disturbace idicates a lack of respect for the meetig. Do t have the staff sittig i there waitig for the patiet to be brought i. Ideally, let the patiet ad their represetative arrive first ad get comfortable i the room ad let the staff come ito the patiet s space. Use a small, preferably roud table you are aimig for safe ad itimate ot big ad exposig. Roud tables help reduce hierarchy ad eable everyoe to see each other. Keep the group small ad relevat. Oly people who have somethig to cotribute should be there ad the patiet should have coseted to them beig there. Make sure the team are briefed o what you expect of them before ad durig the sessio (especially that they are there to cotribute, ot to watch). Silet observers (eve if they are itroduced at the start) create a audiece rather tha a collaborative presece. At the start of the meetig make sure everyoe is itroduced, the purpose of the meetig explaied ad everyoe s role made clear. 44

49 Make sure everyoe has a drik (all the same ot that staff have tea ad others have water uless that is their preferece). Make sure all the chairs are the same. The service user sitig o a small chair ca feel vulerable but sittig o a higher chair ca feel like beig i court. Thik carefully about the use of laptops/computers etc. i the meetig they ca make thigs go faster from our poit of view but ted to reiforce the power differetial i the room ad reduce the level of egagemet from participats. Flip charts ad pes are much more egagig. The team obviously eed to meet at times without the patiet or family preset. However, it is ucomfortable to leave a room of people who are stayig behid to talk about you. Could you all leave ad come back together i five miutes? Outcomes The examples of good practice that were gathered durig the developmet of this documet (available o the website) ofte icluded psychology-led multidiscipliary formulatio or case discussio sessios. Whe wards egage i team formulatio sessios, the followig outcomes are observed: Staff report chages i their ow practice: Greater psychological uderstadig Improved recovery focused care Compassioate therapeutic alliace Icreased staff cofidece Improved ability to provide a cosistet approach Positive maagemet of complex problems Measured reductios i: Average legth of stay Readmissio rates Harm ad falls durig admissio Summary Formulatio is core to puttig the idividual eeds of the patiet at the heart of care plaig ad must, above all else, produce a map of how to improve the psychological wellbeig of the patiets ad carers who are makig use of the service. That is, how therapeutic chage ca occur; how thigs ca be better tha they curretly are ad how ca this be sustaied? The questio of who is formulatio for? should be kept alive ad cotiually revisited. It is helpful to maitai that the patiet is ot a by-product of a system, but a perso aroud which a system is built. Therefore, the outcome of ay formulatio must be better idividual care; it must be a pla for possible chage. The ipatiet cotext is a settig offerig great potetial for therapeutic chage, or a reductio of further harm, which is a worthy aspiratio. Natasha Lord, Stephaie Petty, Lee Harkess & Sarah Dexter-Smith 45

50 Refereces America Psychological Associatio. (2014). Guidelies for psychological practice with older adults. The America Psychologist, 69(1), 34. College Cetre for Quality Improvemet. (CCQI; 2017). Stadards for ipatiet older adults metal health services: Fourth editio. Lodo: Royal College of Psychiatrists. Dema, C. (1995). What is the poit of a formulatio? I C. Mace (Ed.) The art ad sciece of assessmet i psychotherapy. Lodo: Routledge. Departmet of Health, (2001). Natioal service framework for older adults. Lodo: Departmet of Health. Hickma, G. & Crawford-Docherty, A. (2010). Ward C: A formulatio-based service developmet programme. PSIGE Newsletter, 112, Hull, A., Dexter-Smith, S. & Prescott, T. (2015). The impact of psychological formulatios o care plas i older adult metal health ipatiet uits. Upublished doctoral thesis, Teesside Uiversity. James, I.A. (2011). Uderstadig behaviour i demetia that challeges: A guide to assessmet ad treatmet. Jessica Kigsley: Lodo. Johstoe, L., Whomsley, S., Cole, S. & Oliver, N. (2011). Good practice guidelies o the use of psychological formulatio. Leicester: British Psychological Society. Johstoe, L. & Dallos, R. (Eds.) (2013). Formulatio i psychology ad psychotherapy: Makig sese of people s problems (2d ed). Lodo: Routledge. Keedy, F., Smalley, M. & Harris, T. (2003). Cliical psychology for ipatiet settigs: Priciples for developmet ad practice. Cliical Psychology Forum, 30, Laidlaw, K., Thompso, L.W., Dick-Siski, L. & Gallagher-Thompso, D. (2003). Cogitive behaviour therapy with older people. West Sussex: Joh Wiley & Sos. Moore, P. (2007). Formulatio diagrams: Is there more tha meets the eye? Cliical Psychology Forum, 174, Murphy, S.A., Osbore, H. & Smith, I. (2013). Psychological cosultatio i older adult ipatiet settigs: A qualitative ivestigatio of the impact o staff s daily practice ad the mechaisms of chage. Agig ad Metal Health, 17(4), Persos, J.B. (1991). Psychotherapy outcome studies do ot accurately represet curret models of psychotherapy. America Psychologist, 46, Schö, D.A. (1987). Educatig the reflective practitioer. Sa Fracisco: Jossey-Bass. Tarra-Joes, A., Dexter-Smith, S. & Mucer, S. (2016). It was almost like a awakeig. A iterpretative pheomeological aalysis of service-users ad carers lived experieces of team psychological formulatio. Upublished thesis, Teesside Uiversity. 46

51 Chapter 5: Speakig the ward s laguage Laguage icludes or excludes, facilitates or disempowers, jois or separates ad defies membership of groups, whether itetioally or ot. Liguistic research has log highlighted that the laguage we use shapes what we our experiece of beig huma. Appreciatig Laguage is a uiquely huma gift, cetral to thik about thigs (Bier, 2017; Boroditsky, its role i costructig our metal lives brigs 2009). Whe you joi a ipatiet team, it s us oe step closer to uderstadig the very worth spedig time workig out how iformatio o the ward flows, betwee who, Lera Boroditsky ature of humaity. ad about what. You might also sped time Professor of Psychology at Staford Uiversity workig out whe commuicatio occurs. There will be formal meetigs ad hadovers but there will also be key uspoke methods of commuicatio that you eed to make use of. Ad each cotext will chage what is said. There are complex decisios to be made about what laguage you adopt at differet times, whe you embody separateess for the sake of modellig ad whe you joi, ad how the laguage that is used defies the purpose of the activity ad the positio of the people i it. It ca be demoralisig to realise that we are strugglig with commuicatio whe we arrive i a ipatiet service. But workig i semi-closed, fast movig eviromets that are, by their ature, ofte focused o other high priority agedas, ca be bewilderig. Com- 47

52 muicatio processes leart from commuity services do t always traslate effectively to ipatiet eviromets: ipatiet services are more direct ad immediate; staff commuicate i less formal ways; ad it is ofte harder to choose the membership ad timig of a coversatio tha i the commuity. What you eed to commuicate ad to whom will dictate where you aim your message e.g. i oe service urses read care plas, maagers read risk registers, psychologists ad psychiatrists read letters. Ipatiet teams may have a very strog group (rather tha idividual) idetity which has formed over may years ad ca be hard to break ito. Do t waste time tryig to chage processes of commuicatio if the pre-existig oes ca be made to work for you. Thik broadly research the differet laguages of policies, cliical records, meetig structures ad operatioal processes; remember that these are all commuicatio strategies that you could tap ito. You should also be familiar with our ow professioal guidelies o the use of laguage (BPS, 2015). Everythig you do commuicates your values about the service, your colleagues, ad the people they are tryig to help, so thik carefully about how you commuicate ad do t uderestimate the complexity i this system structure. Util you uderstad the stakeholders ad existig culture you ca t make useful decisios about sometimes fraught choices: do you go to that meetig you perceive as uhelpful ad challege what is happeig, or stay away?; what are you commuicatig to whom with each decisio? There is a iheret tesio betwee: 1. the seemig simplicity of commuicatig with a team that is always i oe place, share a eviromet, have a strog idetity, ad whose patiets are early always available ; 2. the reality of shift workig (you will oly ever be able to talk to a small proportio of the team at a time), disparate group cultures, the speed of turover (sometimes of staff as well as patiets), ad the rapid ature of decisio-makig by the team that ofte chage day to day ad do t match your workig hours. There are may laguages we eed to speak as psychologists i ipatiet eviromets ad Table 1 outlies key thigs to bear i mid. Some of these are the formal laguages of social care, metal health law, physical health, bed maagemet etc. Others are much more subtle uwritte commuicatios of how that ward team egages i emotioal processig with each other. Is this a team where it is OK to say that a particular idividual frightes you or that you are irritated by someoe ad eed some space? The emotioal demads of beig i a relatioship with the same group of patiets for a whole shift must be commuicated ad processed somehow e.g. is it by a level of dissociatio, the developmet of heroes, or collaborative peer support? The laguage that you use ca provide a sese of cotaimet for yourself ad those aroud you, or coversely icrease levels of axiety ad distress. Natioal guidelies ca add a exteral objective ratioale for tacklig problematic laguage that may be so egraied it is hardly oticed (DEEP, 2014; BPS, 2015). Cultural assumptios ad iequalities are uwittigly perpetuated by the way the domiat discourse pervades geeral iformatio, e.g. the assumptio of heterosexuality. Ageism is ufortuately part of this domiat discourse ad it is importat to be alert to it; it is so widespread that it is easy to overlook ad ca form part of the discourse of patiets, 48

53 Table 1: The laguages you may speak. DO Be aware that what you say ad how you coduct yourself is costatly commuicatig your core values. Use the laguage of recovery ad talk about people s lives, prefereces, persoal goals ad what gives them joy or satisfactio. DON T Isist others lear your laguage i order to uderstad you. Do t expect operatioal colleagues to speak a cliical laguage. Mistake the processes of commuicatio for the purpose of commuicatio. Express useful psychological ideas i plai speech. Adapt the pace of your commuicatio to the cotext ipatiet services are fast movig. Be ready to give a imperfect or half-fiished opiio if it provides a useful startig poit. Cosider actig the solutio i teams where power is very ubalaced: as though everyoe is a valued member ad opiios are already welcomed ad listeed to. Thik carefully about whe it is helpful to mirror the laguage style of the perso you are commuicatig with ad whe it is t. Be aware that you are embedded i the orms of psychology. Sped time ivestigatig what others have bee taught to value ad prioritise. Dress statemets up as questios. Lear to otice whe people just wat to be told what your opiio is. Igore the powerful ways that the eviromet commuicates factors such as the worth of patiets ad staff, however iadvertetly. Fall ito commuicatios that reiforce the stereotype that older people are a homogeous group ad that issues of differece ad exclusio are for the youg. Forget the huge rage of people who may be cotributig to the experiece of care family, medical specialties, physiotherapy, SALT, dieticias, activity coordiators, advocates, research team, safe-guardig, ifectio cotrol, advocacy, police, support workers, voluteers, housekeepig, studets, chaplaicy, admiistrative staff, social workers, metal health office. Lear the laguage of physical health. You eed to be able to uderstad ad commuicate about blood pressure, kidey failure, diabetes, ifectio etc. i order to uderstad the complexity of the problems other team members are grapplig with. Igore what might be happeig whe people tell jokes these are ofte the times whe the ucomfortable emotios get discharged or moral judgemets get made. Make thoughtful decisios about how to commuicate disset ad dissatisfactio. Is this a situatio that requires formal reportig? Cosultatio with the ward maager? Direct cofrotatio? A private word behid closed doors? Curious questioig? Talk about psychological ideas, especially those which ca help the service to deliver high quality ursig care: Midfuless, attachmet, locus of cotrol etc. Cosistetly referece the variety of huma experiece ad idetity (sexual, cultural ) i your ow commuicatios ad ask questios about the provisio for people with protected characteristics. Igore the powerful commuicatios staff make to each other about hierarchy ad the value of people s opiios. Stop reviewig the laguage you are usig yourself ad the message it is givig. Uder-estimate the cultural differeces betwee the 4 atios. Laguage impacts o how people thik ad Welsh is a atioal laguage alogside Eglish. families, ad staff. Look critically at the iformatio your service provides. Do your pamphlets, sigs, ad eviromet actively ackowledge differece or are issues of differece ivisible util idividuals self-idetify as outside the orm? This ca be particularly difficult i services for older people where there is typically a geeratio or two gap betwee the 49

54 staff ad the patiets, ad ofte a geeratio gap betwee patiets themselves. Laguage is icredibly fluid ad chageable; differet age cohorts use laguage differetly i ways that reflect the differet philosophies ad ethical dilemmas that people have eeded to atted to at differet poits i history. Look at models of co-productio ad thik with patiets ad families about how they ca support a chage i laguage ad commuicatio o the ward. Go back to basics. Remember all the ways i which you, the patiet, team ad orgaisatio are commuicatig: , coversatios, patiet records, policies, body laguage, what you prioritise whe meetigs clash, what you challege, the built eviromet etc. What are you doig that promotes or hiders geuie uderstadig from the wider team? Our experiece is that there is a very powerful relatioship betwee the use of laguage ad actig the solutio. If you begi your coversatios with a accout of the patiet s cocers ad priorities there is a impact o team discourse. People get used to talkig ad thikig i certai ways ad you ca iitiate cultural chage by kick startig chages i the style ad cotet of coversatio. Who are you commuicatig with? This is heavily iflueced by whether you ad other stakeholders have clear roles ad a clear poit to the perso s admissio ad the maturity of the relatioships that you have with each other. It s importat to uderstad what roles are beig acted out ad what roles you are beig ivited ito or to witess/codoe (passively or overtly). Cogitive Aalytic ad Trasactioal Aalysis models might be particularly useful here. Make a coscious decisio about what you re takig o/takig part i etc. Commuicatig your commitmet to team membership happes via may tiy acts ad gestures. Makig tea ad havig a chat are ot acts that require psychological techique but the decisio about what to (ot) take part i might be part of a sophisticated ad well-thought out commuicatio strategy that is based o psychological formulatio. Table 2 summarises the key people with whom we might be commuicatig. What are you commuicatig about? All systems, (especially closed systems) have both overt, domiat arratives ad more subtle arratives alog with rules about which arratives are sileced or discouraged. Mappig the dialectics i play ca help you to idetify what is beig said, what is (ot) beig give thikig time, ad where you might fid ways of creatig commo groud whilst also creatig space to create chage withi the team. Words such as us ad them, ill ad well, diagosis ad formulatio, patiet ad service user all carry strog meaigs ad ca be difficult to recocile with the pressure to move to more recovery orietated ways of workig. Keepig the impact o the patiet at the cetre of all commuicatio ca prevet some of the dehumaisig/distacig process words (beds/delayed discharges etc.) comig to stad for the idividuals who eed care. A stregth of our traiig as cliical psychologists is our ability to draw o multiple models to iform assessmet, formulatio, ad itervetio i relatio to idividual care, team dyamics, ad orgaisatioal processes ad to embrace ucertaity. But i commuicatig 50

55 Table 2: Who you commuicate with. Patiets Families ad carers Cliical staff/teams Wider orgaisatio Depedig o the cohort ad cultural mix of the local populatio, several differet laguages will probably be spoke, particularly i Welsh services. Some Asia laguages have quite differet liguistic ways for talkig about metal health ad this ca frame the patiet ad family uderstadig of the difficulties they experiece. Also look out for: behavioural commuicatio; use of the physical space; the degree to which people socialise; how physically active people are, ways i which their appearace may be commuicatig somethig, ad whether they exercise their freedom to leave the ward. Iterpreters are importat i helpig staff uderstad ot just the laguage spoke but also the meaig that is beig commuicated by cultural stories, symptoms, ad descriptios of distress. Do t assume that close family will idetify themselves as carers. Our blaket use of this term ca exclude ad distress or burde people with a sese of resposibility that they are ot willig or able to fulfil. The psychological cotract i eve close relatioships does ot ecessarily iclude carig for the other perso. Thik with families ad patiets about the ways they have commuicated betwee themselves (style, words etc.), what is t comfortably said or heard, what is withi the capacity of differet relatioships, ad what is give priority? Formal/iformal meetigs, documetatio, supervisio forums, traiig processes. Who atteds ad speaks, where, how are people addressed (verbally ad i writig), how are thigs (keys/ uiforms/offices etc.) allocated? Is the laguage betwee teams supportive or cofrotatioal? How are trasitios betwee teams commuicated to everyoe? What is give priority/measured/fuded (icludig the built eviromet)? Who sees what reports (thik broadly)? What processes get talked about most (serious icidets, talet maagemet etc.)? What gets ito the busiess pla/who is give resposibility ad accoutability for what? What accreditatio ad regulatory stadards are prioritised? with other staff, there is a balace to strike i how you use those multiple perspectives. I a fast paced, high hazard eviromet, people (patiets, staff, maagers etc.) eed some cotaimet i how you commuicate your professioal opiio. That does t mea buyig i to false certaity but it s ot always helpful to show all your workig out or refuse to make a decisio. This ca be difficult especially if you are ew to the professio or to ipatiet work. So use supervisio or a metor to help you thik through who eeds to kow how broadly you ca thik ad who eeds some more cocrete advice. Fid a way i There are some key factors to hold i mid whe thikig about how to structure your ow laguage: There is a careful balace to be achieved betwee usig laguage of cocer ad tellig stories of success ad it is importat that you are thoughtful about the timig, cotext, purpose, ad audieces for your message. However, tellig stories of success is icredibly valuable. As log as you are tellig stories of the team s success, you cotribute to improved morale, icrease self-belief i their ability to make chage, ad positively ifluece exteral arratives about the team. You also start to cotribute to a shared uderstadig of what good looks like ad specific ways i which each perso ca cotribute to that. Make sure you commuicate safety ad predictability by: your time keepig; your 51

56 emotioal reactios (beig cogruet ad predictable rather tha emotioless); followig through o promises; a stable focus o what is importat; ad how you talk about other people especially whe thigs are cotetious (all your coversatios are professioal ad are beig oted by others). All cultures have a domiat arrative ad older people s ipatiet uits are o exceptio. Feedback from the FPOP membership clearly articulated cocers about how to fid a voice for commuicatig psychological messages i a world of ECT, ketamie ifusios ad TMS. Medical laguage ofte domiates for may reasos, ot least because a lot of the people usig the service are physically uwell. But there will always be a way i look for what is worryig key stakeholders i their coversatios ad brig i a alterate perspective. Groups form i all eviromets; usually we re a sigle psychologist. What, if ay, groups do you joi? What stories will people tell about that? Thik about e.g. where your photo goes o the ward board, where you sit, where you have luch, how is your (ad others ) title (ot) used i coversatio/miutes/itroductios etc. You might eed to commuicate differetly with differet groups. People uderstad that. But make sure that, eve if the words/format/vehicle of commuicatio differ, the core message ad values of your commuicatio do t people will rapidly see through that ad lose cofidece i you. We ecourage you to thik widely: stories of successful commuicatio have ofte come from the multitude of ways i which we commuicate whether we value the patiets, team ad orgaisatio as much as we value ourselves ad psychology. Do you: Joi the team for coffee breaks/offer to make coffee sometimes. Keep your door ope ad actively move ito the spaces o the ward that have traditioally bee avoided. Stad up for sileced arratives or go with the domiat flow. Work o cliical or operatioal policies or service reviews shapig them ca alter the commuicatio flow of a ward for years. Summary Pick some key messages ad keep repeatig them i as may places as you ca. Reletlessly commuicate that you wat to be there ad wat to help make the uit a more therapeutic place for everyoe. Use your psychology skills; build relatioships, take time to make sese of commuicatio, challege appropriately, ad have well thought through opiios. Above all, remember that your commuicatio i all its forms portrays your respect for the other people o the ward. Whe you get it right it goes a log way to makig your work more effective ad your job more ejoyable. Kate Ross & Sarah Dexter-Smith 52

57 Refereces Bier, B. (2017). Does the laguage I speak ifluece the way I thik? Liguistic Society of America. Retrieved 23 March 2017 from Boroditsky, L. (2009). How does our laguage shape the way we thik? boroditsky-how-does-our-laguage-shape-the-way-we-thik British Psychological Society/Divisio of Cliical Psychology (2015). Guidelies o laguage i relatio to fuctioal psychiatric diagosis. Leicester: British Psychological Society. Demetia Egagemet ad Empowermet Project (DEEP, 2014). Demetia words matter: Guidelies o laguage about demetia. 53

58 Chapter 6: Culture chage Itroductio The treatmet of psychological distress ad demetia has historically bee shaped withi a biomedical framework. Cultures of care for older people have bee described to us as task-focused ad lackig hope i their approach to those with icurable coditios or those who have ot respoded to medical treatmet. However, social cotext, expectatios of patiets ad staff, ad models of care have all chaged i recet years. There are may examples of iovative practice which have addressed some of these historical approaches ad this is a fruitful time to egotiate chage i healthcare settigs. The icreasig multidiscipliary sig up to the recovery model, the shift i operatioal focus towards quality, ad the ivestmet i leadership developmet reflect this emergig climate of ew possibilities. Health care practice ad policy highlight the fudametal role of orgaisatioal culture i eablig good metal health care (Rafferty et al., 2015) ad this chapter outlies how you might begi to thik about the culture of care i which you work. It brigs together themes from other chapters (particularly the key offer, therapeutic egagemet, ad speakig the ward s laguage) ad cosiders them at a systemic level. There is eormous 54

59 iterest i leadership ad chage methodologies withi the NHS ad recet examples of systemic poor care have created a welcome shift i emphasis to what eables healthcare orgaisatios to work collaboratively ad compassioately (e.g. Berwick, 2013). This chapter focuses o applyig the psychological models that form a core part of a psychologist s toolbox withi the specific cotext of older people s wards but these models ca be ehaced by a broader readig of the literature o leadership ad orgaisatioal chage. The Kig s Fud ad the NHS Leadership Academy produce regularly updated resources ad iformatio i this field. A importat startig poit for you ad the wider service is to cosider what a healthy culture of care looks like? At the broadest level, the priciples of digity, compassio, competece, safety ad choice are see as essetial to good quality care (Departmet of Health, 2015). A healthy culture of care is also oe which develops the employee s capacity for hope, resiliece, optimism ad self-efficacy (psychological capital) ad i doig so maitais good performace, wellbeig ad satisfactio (Luthas et al., 2008). Withi metal health services, a good culture of care would be oe which edorses a uderstadig of metal health from a rage of perspectives, with each patiet s uique eeds at the cetre. Both recovery ad perso-cetred approaches are ofte referred to as aspiratioal frameworks for metal health ad demetia services. These two approaches share much commo groud, both emphasisig the role of hope, idetity, coectedess ad purpose as fudametal to emotioal wellbeig (Slade, 2013; Perkis et al., 2016). Both also recogise the importace of the idividual s relatioship with their socially prescribed idetity through e.g. issues of geder, ethicity, sexuality, ad ageism. The way i which these idetities are supported is ofte a importat idicator of the health of a culture (for patiets, staff ad families). Spedig time specifically thikig about the ipatiet culture i which you work is critical i helpig services move towards recovery-based psychologically iformed care. The priciples of culture chage draw o may core psychological models familiar to all applied psychologists as well as o the critical ifluece of processes, practices ad structures i uderpiig culture. For clarity, this chapter will use cogitive behavioural theory as a framework for illustratio as this is, to some degree, familiar to all psychological practitioers ad metal health professioals. This does ot suggest that CBT is the oly model through which this work ca be developed; rather, ay psychological model which is appropriate ad preferably familiar to the service i which the psychologist is workig ca be applied withi this framework. This chapter will focus o how to support the developmet of a psychologically healthy culture through assessig, formulatig ad iterveig i the domais of idividual sese-makig ad behaviour, ad the orgaisatioal systems that hold these i place. It begis by defiig culture ad presetig a theory ad framework for uderstadig cultural chage. It cotrasts a CBT approach to Schei s (2010) model of culture to support those psychologists who are begiig to move from idividual work to orgaisatioal itervetios. However, it is importat to recogise that other psychological models, especially systemic theory, will have equal validity i thikig about this process of cultural chage. 55

60 What is culture? Culture is defied by the Cambridge Eglish Dictioary as the way of life, especially the geeral customs ad beliefs, of a particular group of people at a particular time. Withi orgaisatios, culture comprises both subjective elemets of life (idividuals thoughts, feeligs, beliefs ad values), ad the more objective or observable structures ad processes that support ad stregthe those subjective elemets. Accordig to Schei (2010), there are three levels to culture, which i may ways provide a parallel to CBT s levels of schemas, coditioal assumptios/ rules for livig ad accessible automatic thoughts ad behaviours. These are outlied i Table 1. I reverse order, the observable level of culture, (the equivalet of thoughts ad behaviours), are called artefacts. These are visible, for istace, the eviromet, the routies, the meetigs, the clothes wor, or the words spoke ad writte. These elemets are straightforward to observe but trickier to iterpret. Their iterpretatio relies o accessig the ext or deeper level of the culture. The ext level of culture is that of espoused beliefs ad values. Followig our CBT aalogy, these parallel rules for livig are the shared values ad beliefs of the group. These have bee developed over time through a process of successfully applyig them to problems ad dilemmas, thereby establishig their place i the espoused way we do thigs aroud here. Needless to say, there may be cotradictios betwee differet sets of espoused values; for example, those that promote a value of beig perso-cetred with the associated artefact of spedig quality time with patiets, with those that promote the value of safe care as practiced through effective ad thorough record-keepig. These values each require differet sets of behaviours or artefacts which, whe time is scarce, presets a potetial coflict. The cosistecy we see i resolvig this coflict is produced through the deepest level of culture; basic uderlyig assumptios or, i CBT terms, schemas. Basic uderlyig assumptios are take-for-grated, ivisible theories-i-use (Argyris & Scho, 1996). They are uquestioed, ideed their presece is uackowledged, the culture equivalet of breathig air; ay alterative way of thikig ad its associated way of behavig is icoceivable. They tell team members what to pay attetio to, what thigs mea, how to react or feel, who they are, what they value, what to feel good about. If such assumptios are iadvertetly challeged, cofusio may result through a failure to uderstad or eve through the misiterpretatio of situatios or evets. As i CBT, these assumptios protect the idividual ad group from the axiety that derives from people s eeds for certaity i a ucertai world. Chage provokes axiety. To chage a team culture, people have to ulear beliefs, attitudes, values ad assumptios ad relear ew oes. This causes axiety because people ted to like order ad cosistecy i what they do. To avoid this axiety, people ted to thik about evets aroud them as i lie with the way they curretly do thigs. This may mea distortig, deyig, or falsifyig to themselves what is really goig o. (NHS Istitute for Iovatio ad Improvemet, 2007, p.25). It is also worth referrig to Mezies (1975) paper o orgaisatioal defeces agaist axiety. This provides aother way of formulatig a task-drive culture ad cosiders why staff might use dehumaisig labels or why there may be a motivatio to distace psycho- 56

61 logically or physically from the patiet, makig meaigful relatioships more difficult. To go further, ot oly does effective culture chage ivolve ulearig at a idividual or group level, but also uravellig ad redesigig the systems ad processes that hold the curret cultural beliefs, values ad assumptios i place, that positively reiforce ad support some behaviours ad artefacts ad udermie others. Culture chage iitiatives that focus purely o values, beliefs ad behaviours ad fail to address this reflexive relatioship by which they are reiforced will fail to achieve lastig chage. Note that the dichotomy betwee traditioal ad recovery models of care is itetioally created to exemplify the poit. Typically there will be elemets of both i a healthcare eviromet. A framework for culture chage The most familiar framework for chage for psychologists is that brought to idividual cliical work; assessmet, formulatio, itervetio ad evaluatio. Whe we are talkig about culture chage the cliet becomes the service ad this might offer a good opportuity for patiets ad families to take a active role i co-producig the assessmet, formulatio ad itervetio with the service. A period of pre-assessmet is importat whe thikig about potetially wide scale chage. This might iclude the reaso for the assessmet (your reaso ad others ), the scale of agreemet o the goal, thought about the relevat stakeholders, ad the potetial use ad distributio of iformatio that the project ucovers. You will also eed to cosider readiess for chage ad the resources available to the service to effect this chage, i order to decide whe to itervee. Prochaska ad DiClemete s (1983) tras-theoretical model of chage with its emphasis o the stages of pre-cotemplatio ad cotemplatio is as applicable to orgaisatioal systems as to idividual people. Ideed, orgaisatioal developmet professioals have developed this model for use with teams as evideced i the work of the NHS Istitute for Improvemet ad Iovatio ad the Divisio of Occupatioal ad Orgaisatioal psychology (Tate et al., 2014). I order to assess culture, you eed to develop a hypothesis about what artefacts or idicators are relevat. The formulatio ca the be derived from the observatios ad the coversatios you have with team members about how ad why they do thigs. The dyamic relatioship betwee these elemets ad the positive ad egative reiforcemet schedules that support them would comprise the itervetio pla. For example, whe cosiderig the presece of a psychological culture i a ipatiet team for older people, the assessmet would collect data idetifyig the artefacts cogruet with this culture ad the formulatio would put them i the cotext of the uderlyig rules for livig, schemas ad reiforcemet schedules which hold them i place (Hickma & Crawford-Docherty, 2010). Artefacts could iclude: The way tasks are described e.g. helpig a patiet to have a meal vs feedig a patiet. What team members recogise as a legitimate task e.g. is social iteractio regarded as a legitimate task i the same way as persoal care or drug admiistratio. 57

62 Table 1: Levels of culture mapped to cogitive behavioural theory. Schei s levels CBT traslatio Real world examples: traditioal care Real world examples: recovery, perso-cetred ethos Artefacts Automatic thoughts ad observable behaviours Eviromet e.g. miimal space for persoal belogigs. The way tasks or problems are described e.g. feedig a patiet, kickig off, attetioseekig. Patiets idetity represeted i their persoal space. Laguage that supports patiets stregths ad recogises distress/ umet eed. Staff-patiet iteractios i.e. professioal-led ad task focused. Routies that just meet eeds of service e.g. meal times, ward rouds, medicatio rouds. Audit programmes/what the service is measured o reflect service rather tha patiet goals. Reliace o agecy staff ad high level observatios to maage risk/agitatio. Fixed visitig time ad rules about what visitors ca/ot take part i. Rich iformal staff-patiet cotact evidecig kowledge of life of patiet, staff egage with patiets betwee tasks etc. Care routie tailored to patiets prefereces ad eeds. Targets that promote a recovery/ perso cetred ethos e.g. are carepla objectives perso-cetred ad meaigful i cotext of patiet s life story. Use of appropriate therapies to ehace wellbeig. Espoused beliefs ad values Rules for livig/ coditioal assumptios If the patiet has demetia, the s/he is uaware of what happes aroud him/her. We oly eed to kow about health eeds (brai scas ad blood tests). There s o poit talkig with them, they do t uderstad. If they are t motivated, it s because they re old what do you expect. We are resposible for their safety/have a overridig duty of care. Protocols that drive passive, cotaiig, riskaverse practices. Patiets are people with rich life histories I eed to use that i my care. If I help my patiets feel relaxed ad happy, I am cotributig to their quality of life. It must be so scary for my patiets to ot be able to remember where they are. Protocols that drive perso-cetred care. Uderlyig assumptios (theories-iuse) Schemas Good ursig is about meetig all of your patiet s physical eeds. Carig for them. Ageist myths e.g. you ca t teach a old dog ew tricks. Disease fatasy i patiets ad staff e.g. the doctor will sort it out. Good ursig is about carig about my patiets as people, adaptig my practice to meet their idividual eeds. Orgaisatioal policies that promote perso-cetred, recovery practice. Biomedical assumptios about metal health/ demetia. Orgaisatioal policies that promote riskaverse, passive care. 58

63 How specific tasks are carried out e.g. the presece or absece of coversatio durig persoal care or durig oe-to-oe observatios. What iformatio is deemed relevat for hadig over betwee team members or recordig i otes e.g. icidets ad medicatio or what has worked well with a patiet ad what has bee leared about their life. I assessig the rules for livig, explaatios would be sought from team members o their ratioale for the behaviours ad systems idetified as artefacts, with schemas idetified through the presece of uderpiig themes that are pertiet to the philosophy uderlyig differet models of care. A assessmet would also iclude the processes by which the desired behaviours are triggered ad reiforced. That is, how the processes would produce behaviours ad sese-makig cogruet with the psychological ethos ad how they would be held i place through the positive reiforcemet provided i the form of cliical supervisio, reflective practice, audits, reportig ad patiet feedback systems. It is also importat to uderstad with the team the developmetal history of the ward culture, usig systemic practice to uderstad multigeeratioal legacies of risk, loss, cotrol, crisis, hope, recovery etc. The impact of wider societal experieces, power ad beliefs about care are also importat to take ito accout. Culture chage at a team ad service level is predicated o producig differeces i sese-makig ad behaviours o the part of cliical ad operatioal staff. The articulated ad observable differeces i behaviour ad other artefacts are achieved i much the same way as ay behaviour chage eterprise is embarked upo i the domai of psychological therapy. Commo elemets of a geeric theory of chage uderpiig ay therapy model (Evas, 2013) are equally critical to culture chage. The elemets of chage are relatioships, commitmet to chage, ew sese-makig ad behaviour chage. Thus a relatioship with the other members of the team is a essetial pre-requisite to ay chage work, just as it is with a cliet eterig therapy. Such a relatioship provides a foudatio of trust ad cotaimet, which are both critical i helpig colleagues alog the emotioal jourey towards makig chages i their thikig ad behaviours ad adoptig differet care models (Weisbord, 1987, 1989; Emery & Trist, 1973; Schei, 1999). Therapeutic models are equally powerful i this cotext for helpig you cosider who is defiig the chage that eeds to happe ad who has idetified the eed for chage. For example, if the desire is that the ward staff should behave differetly or adopt a differet set of beliefs or approaches, who will defie what chage is eeded or what the desirable outcomes are? Are you i a cliet-cetred situatio where the set of people who will eact the chage are empowered to develop their ow visio of a preferred future or are the people defiig the goal ad the people who are supposed to be chagig their behaviour two differet groups? Solutio focused (McKergow & Clarke, 2005) ad trasactioal models (Moutai & Davidso, 2011) may provide useful frameworks alogside systemic models for cosiderig these dyamics. Similarly to oe-to-oe therapy, the relatioships betwee the people ivolved i cultural chage brig power to the itervetios. Helpig the team idetify what s i it for them through cliical techiques such as motivatioal iterviewig produces the catalyst for, ad commitmet to, the chages to come. Commitmet to chage is iflueced through 59

64 idetifyig the eed for chage, elicitig the self-belief i a team that they have the ability to produce the required chages, ad helpig them idetify what they will gai for themselves. This motivatioal work also eeds to iclude other stakeholders such as maagers ad cliical leaders who idirectly ifluece the operatio of the ward. Experiece shows that chage is much easier to achieve ad embed whe the psychologist works closely with the team ad service maagers. How you have positioed yourself withi the team will ievitably ifluece this. Co-productio ca also be achieved by ivitig patiet ad carer represetatives ito this process of egotiatig a shared goal. The developmet of ew sese-makig ad behaviours are commo itervetios delivered by psychologists withi ipatiet settigs. Skills developmet programmes comprisig traiig, skills practice, ad supervisio or reflective practice are commo offers from psychologists workig withi ipatiet services. They are more likely to be successful if they are desiged i accordace with the overall formulatio of the culture chage required withi the settig, as well as the stregth of the relatioship established with the team members. This should iform decisios regardig legth, format, style (e.g. didactic vs coachig), the eed for further support to traslate to practice (policies, paperwork, supervisio), ad reiforcemet systems that demostrate to colleagues that this matters (e.g. operatioal maagemet coversatios, audits of behaviours, reportig systems). Evaluatig the impact of orgaisatioal chage work ca be complex but illumiatig. You will eed to work to esure that the chages required by differet elemets of the system are cosidered ad wove together ito a meaigful arrative e.g. balacig cost savigs, workforce chages ad icreased presece of perso cetred coversatios ad care plas. Culture chage that does ot address the eeds of each stakeholder wo t be maitaied ad so plaig for the evaluatio of each elemet from the start is imperative. Workig out how those elemets will fit together i the ew culture will also have bee part of your formulatio i the plaig stage. As a real world example, Schei s model of culture was used by Shaw et al. (2016) i uderstadig the way i which orgaisatioal culture impacts o the way medicatio is prescribed to older people i ursig homes. They used a questioaire based o Schei s three levels to divide culture ito traditioal, perso cetred or ambiguous ad foud that these characteristics iflueced the prescribig of atipsychotics. They also foud four potetial areas for itervetios (characteristics of the settig, characteristics of the idividual, relatioships, ad decisio-makig) that could shift culture towards a more flexible, residet-cetred culture with the possibility of reducig use of psychoactive medicatio. Summary Effective culture chage ivolves the applicatio of core cliical psychology competecies ad frameworks but applied at the level of the team ad orgaisatioal uit. Ad, just as i idividual work with patiets, the societal iflueces of e.g. power, isolatio, poverty, historical ad curret trauma at a group level, eed cosideratio. Culture operates ad is maitaied i much the same way as a idividual s thoughts, feeligs ad behaviour. The artefacts that are visible to the observer are uderpied by beliefs ad values ad 60

65 take-for-grated assumptios, much like thoughts ad behaviours are uderpied by rules for livig ad schemas. These cultural artefacts ad belief systems are maitaied through a system of reiforcig processes such as moitorig systems, audits, ad supervisio which stregthe the orgaisatio s desired behaviours ad allow the udesired oes to fade ad extiguish. Thus, the eterprise of culture chage withi older people s ipatiet services has may parallels with idividual or family work; assessig ad formulatig the curret positio, defiig the desired chage, desigig itervetios ad maiteace mechaisms, ad facilitatig their implemetatio. This framework provides the skeleto upo which may of the orgaisatioal aspects of the work of the ipatiet psychologist ca be hug. Ae Crawford-Docherty & Gemma Graham Refereces A evidece-based framework for desigig skills developmet to esure maximum trasfer ito practice ca be foud o the Health Educatio Eglad website withi the PROMPT olie tool. Further examples of the use of this chage framework are icluded i the accompayig web resource. Argyris, C. & Scho, D. (1996). Orgaizatioal learig II. Readig, Mass: Addiso-Wesley. Berwick, D. (2013). A promise to lear a commitmet to act: Improvig the safety of patiets i Eglad, available at Departmet of Health (2015). The NHS Costitutio: The NHS belogs to us all. Lodo: The Statioery Office. Emery, F. & Trist, E. (1973). Toward a social ecology. Lodo: Pleum. Evas, I. (2013). How ad why people chage: Foudatios of psychological therapy. Oxford: Oxford Uiversity Press. Hickma, G. & Crawford-Docherty, A. (2010). Ward C: A formulatio-based service developmet programme. PSIGE Newsletter, 112, Luthas, F., Norma, S.M., Avolio, B.M. & Avey, J. (2008). The mediatig role of psychological capital i the supportive orgaisatioal climate employee performace relatioship. Joural of Orgaisatioal Behaviour, 29, McKergow, M. & Clarke, J. (2005). Positive approaches to chage: Applicatios of solutios focus ad appreciative iquiry at work. Chelteham: SolutiosBooks. Mezies, I. (1975). A case study i the fuctioig of social systems as a defece agaist axiety. I A. Colma & W. Bexto (Eds.) Group relatios reader (pp ). Sausalito, CA: Grex. Moutai, A. & Davidso, C. (2011). Workig together: Orgaizatioal trasactioal aalysis ad busiess performace. Farham, Surrey: Gower Publishig Ltd. NHS Istitute for Iovatio ad Improvemet. (2007). Improvemet leaders guide: Persoal ad orgaisatioal developmet buildig ad urturig a improvemet culture. Covetry: 61

66 NHS Istitute for Iovatio ad Improvemet. Perkis, R., Hill, L., Daley, S., Chappell, M. & Reiso, J. (2016). Cotiuig to be me: Recoverig a life with a diagosis of demetia. Nottigham: ImROC. Rafferty, A., Philippou, J., Fitzpatrick J.M. & Ball, J. (2015). Culture of care barometer: Report to NHS Eglad o the developmet ad validatio of a istrumet to measure culture of care i NHS trusts. Lodo: Kig s College Lodo. Schei, E. (1999). Process cosultatio revisited: Buildig the helpig relatioship. Readig, MA: Addiso-Wesley. Schei, E. (2010). Orgaizatioal culture ad leadership. Sa Fracisco, CA: Jossey-Bass. Shaw, C., McCormack, B. & Hughes, C.M. (2016). Prescribig of psychoactive drugs for older people i ursig homes: A aalysis of treatmet culture. Drugs Real World Outcomes, 3(1), Slade, M. (2013). 100 Ways to support recovery: A guide for metal health professioals. Lodo: Rethik. Tate, L., Doaldso-Feilder, E., Teoh, K., Hug, B. & Everest, G. (Eds.) (2014). Implemetig culture chage withi the NHS: Cotributios from occupatioal psychology. Leicester: British Psychological Society. Weisbord, M. (1987). Productive workplaces: Orgaizig ad maagig for digity, meaig ad commuity. Sa Fracisco, CA: Jossey-Bass. Weisbord, M. (1989). Re-desigig o-routie work: The key is ivolvig more people sooer. Productive Workplaces, 1,

67 Chapter 7: Psychological harm Our aim for this chapter is to raise the profile of psychological harm for all who use the services we work i. We start from the premise that a psychologically healthy workforce is eeded i order to provide safe care. We have selected frameworks that help make sese of the work eviromet so that you ca articulate problems ad suggest solutios. We have ot detailed how to respod to harm whe it occurs but ecourage you to look ito this, particularly as some experieces, such as beig sectioed uder Metal Health Legislatio are commo ad potetially traumatic. We have looked to cocepts of harm i other high hazard workplaces as well as healthcare. Failures i care are more likely whe the best approach remais ucertai ad multiple professioals are ivolved i the care provided (Rucima et al., 2007) : we hope that this chapter helps you ad your teams to thik through the ucertaity you have to deal with i a more coheret ad iformed way. We have specifically focused o those elemets that we have foud importat i older people s metal health services. This quote is worth repeatig i full, replacig customers with patiets : It has bee recogised that there are uique risk factors associated with providig customer services [e.g. i] healthcare. I this type of work the expectatios ad behaviour of customers represet a additioal source of work demads. The self-cotrol required to maage emotios whe dealig with difficult situatios results i what researchers call emotioal work ad may cause strai for employees. I additio to the strai of emotioal work, customer behaviours that threate employees sese of cotrol or self-esteem, which prevet employees from developig good relatios with their customers ad/or which make employees feel isecure durig iteractios with their customers are importat sources of stress. These situatios ted to deplete the idividual s persoal resources, ad emotioal exhaustio, job dissatisfactio ad ill health ca result. (Dollard et al., 2003). Traditioal defiitios of psychological harm ofte focus o actively abusive harm. These are importat but eable us to separate ourselves from the potetial to be part of this dy- 63

68 amic. Harm also occurs i other ways ad care ca be experieced as potetially hurtful or abadoig, prevetig access to sigificat others, humiliatig, blamig, cotrollig, ad itimidatig. It ofte icludes isolatio, ad reduced access to support etworks, all of which ca cotribute to psychological harm (NHS Choices, 2017). This may be compouded by the beliefs of patiets, staff ad families that restrict their digity ad self-efficacy. For example, believig that they caot leave the ward despite beig a iformal patiet or beig excluded from decisio-makig about their ow care/omittig to place value o the patiet s ow views of the situatio. Harm may be mudae or catastrophic ad acts of omissio, delays ad icoveieces ca all have a sigificat impact o wellbeig (Rucima et al., 2007). It is importat to ote that Iatrogeic harm is the atural outcome of the way healthcare is desiged ad delivered. Ideed, the healthcare system has ot really bee desiged at all, but istead evolved haphazardly over time, ad cotiues to do so (Rucima et al., 2007, p.65). Iatrogeic harm is ot limited to the patiet or staff groups. It ca cause very real harm to the self-efficacy, hopefuless ad wellbeig of the families ad people that are close to them. Ad it is importat to ote that there is emergig evidece that psychological itervetios ca also be a source of iatrogeic harm, eve whe itervetios are carried out appropriately (Crawford et al., 2016). Psychological harm ca be caused by ad occur i the ward team, patiets, visitors ad members of the wider orgaisatio. It is a sigificat eough problem that the Australia govermet has produced guidace o strategies to reduce the risk of this type of harm (see Comcare, 2008). Yet psychologists, ad healthcare staff i geeral, are ot ecessarily familiar with these models or frameworks. We are familiar with cliical models of distress ad fudametal huma processes but other high hazard idustries deal regularly with how to orgaise work based systems to support the psychological wellbeig of those who use them. I cliical settigs we are ofte good at reactig to sigs of distress but this ca distract us from oticig systems that seem desiged to create it. A prime example of this might be the impact o health ad wellbeig of people who regularly work through the ight. A helpful broad overview is provided i the Istitute of Occupatioal Safety ad Health (IOSH) guide Promotig a positive culture: A guide to health ad safety culture (IOSH, 2015), which outlies a overview of the foudatios of positive safety culture ad ways i which to improve it. The IOSH model is made up of three parts; workig eviromet, systems maagemet, ad people ad orgaisatio (Figure 1). It is importat to remember that people ad orgaisatio covers patiets, team members ad visitors ad, although there are ofte specific issues for each group, there are eough commoalities that we have grouped them together. Ofte the experiece of oe group is mirrored i the experiece of the other. Team members who are ew or oly periodically work o the ward, visitors, staff who respod to emergecies ad the leave, ad patiets who stay for a very short time may be particularly vulerable as they have less opportuity to share those experieces with other members of the group or to develop relatioships which support help seekig. 64

69 Workig eviromet Systems maagemet People ad orgaisatio Patiets, team members, families ad visitors Figure 1: Health ad safety risk maagemet: maagig the risks associated with iteractios betwee the workig eviromet, the maagemet systems, the orgaisatio ad its people, (IOSH, 2015). Table 1 articulates some of the factors i each area that are worth cosiderig. Obviously, the divide is arbitrary at times but it highlights the broad rage of factors that might cotribute to situatios that lead to harm, i order to begi to address them. The Australia govermet (COMCARE, 2008) make aother useful distictio i the differece betwee harm from the work cotext ad the work cotet. The cotet is ievitably iterspersed with high emotio, precarious relatioal iteractios, makig decisios i fast paced, ucertai ad hazardous situatios, shift workig ad usociable hours. But the cotext (covered i Table 2) does ot eed to exacerbate this. Too ofte i metal health care, especially i acute care, the two are coflated ad the distress perceived as ievitable. This stops people otig what could be chaged ad removes a sese of agecy which is i itself damagig. Issues of work cotext as outlied i Table 2 are very ope to chage ad we all cotribute to how those cotextual factors are implemeted. Up frot coversatios about the items i this table ca help to quickly address some of the factors ad icrease the team s sese of agecy. The followig advice from the IOSH highlights the eed for practical guidace aroud workig practices that is articulated i behavioural terms ad may of the cotributors to the developmet of this guidace have also commeted o the eed to be explicit about what actios ad behaviours are eeded to achieve ethical ad compassioate care. It s hard to chage the attitudes ad beliefs of a workforce by direct persuasio, but by actig safely workers ca start to thik safely. This belief has led to the developmet of behavioural safety approaches. Remember that culture ofte develops slowly, ad that fudametal chage requires time. (IOSH, 2015). It s also importat ot to be complacet as the risk of harm is ever-chagig. Teams that have received positive feedback ca miss sigs that their culture is chagig. Abuse ad eglect ca occur i may types of istitutio, icludig those that seem to provide high-quality care to patiets. A key fidig from a examiatio of iquiries ito scadals i residetial care suggested that a acceptable or good regime of care could be trasformed ito a abusive oe relatively easily ad quickly, with little detectable chage i the outward situatio (Clough, 1999). Ad whilst complimets are hugely importat, they ca also be a ackowledgemet of good care i spite of the evidet problems i a ward (Rucima et al., 2007). 65

70 Table 1: Mappig the IOSH model to older people s ipatiet services. Workig eviromet Overcrowdig. Lack of privacy. Lack of purposeful ad rewardig activities/iadequate sesory stimulatio. Noise. Fiacial restraits. Physical restraits (e.g. locked ward). Upredictable or aggressive behaviour of others i the eviromet. Challegig arrative i the media. A cliical eviromet where multiple ad ofte log-term medical issues mea there is little hope of a cure ad therefore heroic itervetios are uwarrated ad gratificatio at a job well doe is more subtle. Systems maagemet Erosio of idividuality i care. Iadequate utritio. Use of restraits. Low status give to workig with older people. Iformatio ot beig readily available to support uderstadig ad choice. Supportive others ot havig easy access to the patiet. Pressure from outside sources. Chagig structures ad pathways. Is there a agreed limit to workload/stress/flow etc. as there is i other high hazard idustries? Who is this commuicated to ad is a respose guarateed? The degree to which risk maagemet ad recovery are balaced/promoted. Lack of or iadequate traiig. Degree to which madatory elemets of the work day e.g. paperwork, are perceived as supportive of the idividual s ability to provide good care. The orgaisatio s approach to bookig leave ad rotas ad the amout of cotrol that the idividual has over this (ad the impact o ability to atted traiig). People ad orgaisatio The followig factors apply to all the people who work i, use or visit our services. Itimidatig meetigs where people are pushed ito acceptig certai actios. A sese that patiece has ru out with the progress beig made. Buildig a culture of relatioal security (e.g. through staff traiig, reflective practice groups, ward roud, ifluecig maagemet processes, role modellig). Iadequate attetio give to idividuals idetity, developmet, eeds etc. ad little time give to reflect ad heal. Itergroup coflict us ad them across professios, professios ad patiets, maagers ad cliicias. Groups ofte hold positive views of themselves at the expese of belittlig the outgroup, particularly whe oe or more group/s feel uder threat. Disgust: there are ofte situatios that ca trigger this reactio i everyoe who uses ad visits the ward. Disgust has bee show to have strog moral cotet o a cogitive level, which whe left umaaged ca easily become disdai. Coflictig social values/ageist beliefs/cofroted by fears of ow ageig ad morbidity. Fatigue. Feelig udervalued. Loss of cotrol helplessess ad frustratio. Misuse of power to ecourage passivity. Not beig meaigfully ivolved i itervetio or discharge plas. Exposure to traumatic evets. The ripple effect ad loss of a ecessary sese of safety for everyoe ca be destructive. 66

71 Table 2: Work cotext ad associated risk factors for psychological harm (COMCARE, 2008). Workig cotext Orgaisatioal culture ad fuctio Role i orgaisatio Career developmet Decisio latitude/cotrol Iterpersoal relatioships at work Customer related Home-work iterface Risk factors Poor commuicatio, low levels of support for problem solvig ad persoal developmet, lack of defiitio or orgaisatioal objectives. Role ambiguity ad role coflict, resposibility for people. Career stagatio ad ucertaity, uder-promotio or over-promotio, poor pay, job isecurity, low social value to work. Low participatio i decisio-makig, lack of cotrol over work (cotrol, particularly i the form of participatio, is also a cotext ad wider orgaisatioal issue). Social or physical isolatio, poor relatioships with superiors. Iterpersoal coflict (icludig harassmet ad bullyig), lack of social support. The eed to hide egative emotios durig iteractios with cliets/ customers, urealistic customer expectatios, ad/or verbally aggressive cliets/customers. Coflictig demads of work ad home, low support at home, dual career problems. The Health ad Safety Executive (HSE, 2009) cites strog evidece likig risk factors associated with demads, cotrol ad support to health outcomes. This liks to employee health but could just as usefully be cosidered with patiets ad families. Demads Workload, work patters ad workig eviromet; Pressure to get well, accept multiple itervetios, or egotiate relatioships with multiple ew people. Cotrol How much say the perso has i the way that they meet those demads. This ca be very obvious for people who are held uder metal health legislatio but subtly pervasive for may other people withi the service. Support The ecouragemet, sposorship ad resources provided by the orgaisatio ad peers for example. Distress is associated with facig demads ad expectatios that are beyod the perso s skills, abilities ad copig strategies. Acute stressors are ofte more immediately obvious but chroic stressors, whilst ofte overlooked, are pericious. Takig the umber of psychological ijury claims as a idicator of the degree of damage doe, it is the iteractio of a umber of factors over six moths or more that causes the most psychological harm (COMCARE, 2008). The impact of pressure o staff, patiets ad visitors caot be overstated. 50 per cet of psychological ijury claims come from workplace pressure (COMCARE, 2008). That pressure the becomes iheret i the system. Staff pressured to meet expectatios that they feel uable to fulfil will struggle to keep that pressure from havig a impact o their colleagues ad patiets. Pressure to be able to provide a bed for everyoe that eeds oe meas pressure to discharge someoe else. Whe we asked durig our iitial cosultatio evet about psychological harm, we heard about staff hidig i the office ad patiets ad families ot receivig a proper welcome to the ward. Ultimately this ivalidates the people who come ito cotact with the ward at a time whe they are ofte at their least resiliet. 67

72 It s easy to thik about how others iflict this o us ad the teams we work i. It s less comfortable to thik about how we might also be cotributig to those factors. We have all certaily falle ito this; do take time to thik about the way you might be either passig o your ow stress or udermiig team members i oe of these areas (however importat your ed goal is). Pla for the outcome of the assessmets you do especially if it is likely to be egative: how will this be commuicated safely ad by whom ad what support will be put i place to eable people to move forward costructively? Takig thigs forward Noticig these factors i your workplace is oe thig. Havig the cofidece to work towards addressig them relies o a umber of factors; your ow resiliece, the support provided by your etworks, the clarity of your role i the service, ad uderstadig the evidece base to help your thikig ad coversatios. There is icreasig scope to talk to your team about the opportuities to actively measure harm ad ackowledge that harm ca occur despite beig itetios. Duty of Cadour legislatio ca be used to support this discussio ad usig emergig outcome measures of harm, ad icludig harm idicators i service audit, evaluatio ad research is key to puttig harm firmly o the ageda. Make sure you have a supportive peer group ad substatial liks with operatioal or professioal leads as outlied i other chapters so that you have somewhere to discuss ay cocers. It is importat that you are ot isolated ad ca work with others to uderstad ad address ay broader issues. It also esures that you are ot rushed ito actig usafely ad that the roles of other people i keepig the eviromet safe are reiforced. Access to relevat kowledge has a vital role i keepig a orgaisatio healthy (Rucima et al., 2007) ad you ca play a strog part i this. Iterpret publicatios, orgaisatioal data, ad cliical iformatio. Help people make sese of what is happeig, icludig gatherig ew iformatio, ad suggest ways of keepig thigs psychologically soud. Fid ad model safe ways of explorig complaits ad askig for geuie feedback so that stories of harm ca be heard ad acted o. Healthcare systems revolve aroud people uderstadig people is your professio. Do t forget all the models of huma experiece, stress, copig, groups etc. that you leart i your udergraduate degree. Support other people to make sese of their ow ad others distress. I this way you ca help work out which situatios are cocerig but ca be dealt with withi the team ad which are serious eough to eed raisig more formally, icludig to people outside of the service. Liked to this, support the orgaisatio ad your team to thik about how orgaisatioal laguage might be received by the people who have bee harmed. Marti, Chew ad Palser (2017) war about (orgaisatioally) useful aalytical terms such as moderate ad low harm beig assumed to also represet a patiet s experiece. Your psychological skills will help the team ad patiet bridge those potetial gaps i both uderstadig ad experiece ad potetially prevet further harm beig doe. 68

73 Psychologists also have a key role i uderstadig ad facilitatig teams decisio-makig ad it might be useful at this poit to look at the table i chapter 1 outliig suggested levels of resposibility for psychologists. Whe you cosider that more tha half the harm caused by healthcare results from a failure to deliver appropriate care or decidig o courses of actio which are iappropriate (Rucima et al., 2007) it becomes clear that this is a importat but ofte uoticed part of how thigs ca go wrog. You uderstad the cogitive ad emotioal elemets of decisio-makig; have the cofidece to ame whe this might be goig astray. Oe of the most direct thigs you ca do is to become comfortable with your role as a cliical leader i a way that is appropriate to your settig ad your role. The HSE iclude the presece of a effective ( supportive ) leader as itself a factor i reducig the likelihood of psychological ijury, as well as icreasig performace ad productivity (Cotto & Hart 2003). The Healthcare Leadership Model produced by the NHS Leadership Academy (2013) has bee mapped to the differet bads of applied psychologist ad is built o the observable behaviours through which leaders demostrate ethical ad value drive practice (Dexter-Smith et al., 2015). The Scottish Model of Healthcare Leadership (NES, 2014) also outlies the behaviours ad persoal qualities that cotribute to service excellece ad is worth becomig familiar with. Ad whe harm is doe, support the team to maitai good commuicatio with each other ad the patiet/family to esure that further harm is ot doe i the aftermath, either to the people directly ivolved or the others who have witessed the evet. Kowig the team well, will help you fid ways of learig from mistakes ad hearig cocers i such a way that you ca safely, ot reactively, respod to it. Sarah Dexter-Smith, Richard Screeto, Laura Kaye & Paul Whitby Refereces Clough, R. (1999). Scadalous care: iterpretig public iquiry reports of scadals i residetial care. I F. Gledeig & P. Kigsto (Eds.) Elder abuse ad eglect i residetial settigs: Differet atioal backgrouds ad similar resposes (pp.13 28). Bighamto, NY: Haworth Press. Cited i World Health Orgaisatio, World Report o violece ad health, chapter 5 (2002). Geeva: WHO. Comcare. (2008). Workig well: A orgaisatioal approach to prevetig psychological ijury. Caberra: Author. Cotto, P. & Hart, P.M. (2003). Occupatioal wellbeig ad performace: A review of orgaisatioal health research. Australia Psychologist, 38(1), Crawford, M.J., Thaa, L., Farqharso, L. et al. (2016). Patiet experiece of egative effects of psychological treatmet; results of a atioal survey. The British Joural of Psychiatry, 208(3), Dexter-Smith, S., Oddy, J. & Cate, T. (2015). Leadership Profiles for Applied Psychologists: Mappig the Leadership Academy s Healthcare Leadership Model. Cliical Psychology Forum, 276, 4 5. Also at 69

74 Dollard, M., Dorma, C., Boyd, C., Wiefield, H. & Wiefield, A. (2003). Uique aspects of stress i huma service work. Australia Psychologist, 38(1), HSE: Health ad Safety Executive. (2009). How to tackle work related stress: A guide for employers o makig the maagemet stadards work. Suffolk: HSE Books. uk/pubs/idg430.pdf retrieved February IOSH: Istitute of Occupatioal Safety ad Health (2015). Promotig a positive culture: A guide to health ad safety culture. ww.iosh.co.uk/freeguides. Marti, G.P., Chew, S. & Palser, T.R. (2017). The persoal ad the orgaisatioal perspective o iatrogeic harm: Bridgig the gap through recociliatio processes. BMJ Quality ad Safety Olie. bmjqs full.pdf NHS Choices. (2017). Retrieved 25 Jauary 2017 from social-care-ad-support-guide/pages/vulerable-people-abuse-safeguardig.aspx.nhs Educatio Scotlad (NES) (2014). NHS Scotlad Leadership Qualities Framework. (accessed 10 August 2017). NHS Leadership Academy. (2013). Healthcare Leadership Model. accessed 14 August 2017 Rucima, B., Merry, A. & Walto M. (2007). Safety ad ethics i healthcare: A guide to gettig it right. Lodo: Ashgate Publishig. 70

75 Chapter 8: Tips from the coalface Itroductio The role of a psychologist i a ipatiet settig ca be very differet to workig i the commuity. Whilst the aims of reducig distress ad icreasig psychological thikig are similar, beig withi a largely medical team presets differet challeges. We asked colleagues workig i ipatiet services across the UK what they wished they had kow whe they started their work i ipatiet services. The request was a ope oe ad wet out through existig groups ad social media. The chapter is iteded to be read i the spirit of messages of support ad guidace from colleagues i similar services ad we are grateful to colleagues for the respose we received. The commets we received are preseted verbatim to retai the itet of the seder. Three core themes emerged: 1. Relatioships with colleagues. 2. How to be effective i your role: what does ad does t help. 3. Self-care ad resiliece. Themed, verbatim resposes are available i the olie resources. 71

76 Relatioships with colleagues Build effective workig relatioships. If this is the oly rule of thumb you follow whe workig i ipatiets you will be effective, ejoy your role more ad maitai your ow ad others resiliece. Build costructive, respectful relatioships with colleagues of all levels, patiets ad carers alike. Ward teams ca be very close give the time they work side by side i a highly emotive eviromet; you ever kow where relatioships lie ad who will talk to whom. The more effective your relatioships, the more likely your aspiratios will filter through ad become permaet. Foster strog persoal relatioships with colleagues that allow you to focus o a cliet s eeds ad to sustai differeces of opiio. There is a ideal emotioal distace to aim towards with colleagues. Relatioships that become too close are vulerable to istability ad a overemphasised persoal compoet is ot always coducive to objective reasoed debates about cliical issues. Be aware of tribal loyalties; your actios have both a cliical ad a political impact. If you are a loe psychologist the your advatage is that you are less threateig ad ca be a associate member of every other tribe. Do t make your oly iteractios cliical oes, esure you get to kow colleagues as people first. Take time to uderstad your colleagues roles ad their experieces. For example, support workers sped the most time with ad kow the patiets really well. They ca also be preset durig very stressful times o the wards. Offer your support ad take time to value their experiece. Nurses have multiple duties o wards; oe frustratio ca be the amout of paperwork they have which reduces their face-to-face cotact. Agai, value their kowledge ad experiece, be sesitive to the pressures of their role ad highlight how your work ca help them. Uderstad what provokes axiety i team members e.g. icreasig workload or beig made resposible for somethig that might go wrog. The first sig is ofte a focus o short-term ad cocrete (typically medical) tasks, probably i a attempt to create a sese of cotrol. MDT meetigs become like a ward roud i a acute hospital ad the patiet as a perso ca get quite lost. Look closely at what might be goig o i the system ad thik of ways to support the team. Ethuse your colleagues; they ca feel disempowered by the system ad may additioal resposibilities which may detract from therapeutic cotact or iovative practice. Psychiatrists ofte have the pressure of leadig cliically o the patiet s care. Get to kow their professioal prefereces ad cocers. Respect their expertise, ad recogise that psychiatry ad psychology ca build a effective syergy to treatmet. Operatioal colleagues are icreasigly ope to the importace of good psychological care. It s much easier to effect chage if you are workig with the support of the operatio- 72

77 al team, so sped time fidig out what problems they eed to solve ad show them what psychology ca offer i relatio to these. Get a balace betwee beig objective ad part of the team. A psychologist s systemic view is what eables chage to drive quality i care, so becomig too egraied i the ward may ihibit this. You might ot be everyoe s fried all of the time, especially whe you are challegig a method of practice which has bee habitual, but if you have built solid workig relatioships this makes the seas of chage a little less rocky. Make sure your values are trasparet ad cosistet i your various relatioships. People may ot always agree with you but they will respect you ad allow you to challege them (ad importatly, feel able to challege you). The more effective your workig relatioships, the more you ca maitai your resiliece, as you are urturig a carig ad cared for reciprocal way of relatig, which is extremely importat o those days where the wards may be particularly challegig. What helps? To chage the culture of a system takes a miimum of 2 years. Give yourself ad colleagues time ad ote each success. Humour is a good tool to defuse tesio. Remember the power ad importace of beig able to say I do t kow. No-oe expects that you will kow everythig people are admitted because their difficulties are so complex that commuity treatmet has failed. It s really importat to be able to discuss the eed to do othig sometimes so that iappropriate treatmets are ot attempted whe there is o obvious way forward. Try talkig ad behavig as though the world is already the way you would like it to be. Talk to people with whom you would like to have a respectful collegiate workig relatioship as though you already do. Talk to maagers ad strategists as though you are expectig them to have a iterest i what you say i.e. model the solutio. More tha ay other settig, your persoal ad professioal reputatio is paramout. There are a huge ad diverse group of colleagues, most of which will have to form opiios about you based o limited first-had cotact. Take time to make sure you always behave i a way you would be proud for ayoe to see. Be flexible i your approach to cliet work. Cosider therapeutic coversatios with patiets as importat as, or more importat eve, tha therapy as such. Recogise momets that are sigificat/iformative/importat, rather tha usig models where you have sessios of up to a hour. Do t expect people to give you all the iformatio you eed; challege stories about idividuals, read old otes, have lots of coversatios, look for what s missig ad be prepared for meetigs to go i directios you have t aticipated. Providig a psychological formulatio for several patiets as opposed to several sessios with oe patiet ca icrease your iput ad offer somethig useful to more people, rather tha the gold stadard to fewer people. 73

78 Just as i therapy, the team eed to ow the approach or model that you are usig. The ursig team ofte have a much better uderstadig of good psychological care ad a greater persoal commitmet to holistic care tha it might appear help them utilise this. Ask questios about all the medical ad physical health care you do t uderstad it s a real educatio which will help you to make better assessmets of your patiets ad shows that you credit others kowledge ad models others to reciprocate curiosity. Psychology iput may be ovel to some ward teams. Be clear i what your role ivolves. Becomig credible ca be achieved by doig a piece of work with a patiet ad sharig this with the team. A early wi ca be very useful. You ca be a powerful asset ad resource to colleagues who use you appropriately. By demostratig how you ca help colleagues you make it apparet to other members of the team how you ca help them. Muck i ad be preset help colleagues, make cups of tea, offer support, do t be a bystader if there is a icidet. Visibility leads to accessibility; a great quality to develop i improvig the psychological impact of your work. Atted MDT meetigs. You ca impact multiple patiets care i a short period of time, will uderstad others assessmet methods ad outcomes, ad itegrate ito the team more effectively. It is useful to be aware of stereotypes regardig psychologists which you may ecouter. Couter stereotypes by cosciously demostratig positive values i the directio opposite to that predicted by the stereotype. 74

79 Challege where appropriate. Psychologists ofte brig a differet perspective ad this is crucial to patiets receivig perso cetred care, so esure your focus is the patiets care ad offer a differet perspective whe ecessary. Be patiet, push where it moves ad recogise the itese ad rapidly chagig dyamics o wards i a cotext of very limited resources. Offer traiig there are lots of opportuities to ehace the kowledge of the team i psychology ad this is ofte requested. Ruig traiig o wards ca be a challege; be flexible, offer shorter sessios at times that work aroud the ward schedule. The word supervisio meas differet thigs i differet professios. Whe you offer supervisio, esure there is a shared uderstadig of what you are offerig. Kow your policies ad guidelies ad provide a cliical ratioale to your recommedatios. This ca be very effective if you re drivig chage or challegig a suggested treatmet. Recogise where your competecies lie ad how these ca be utilised by other disciplies. Also kow your limitatios ad ask your colleagues from other disciplies for their advice. If you are ot based o the ward itself, but eter it ad exit it, be sesitive to this ad what it might feel like to others who are ot free to do this (patiets ad other members of the team) at the times they wish, or for those detaied. Oe way to approach the perceptio that diagosis is explaatory (ad brig others o board) is to frame diagosis as part of the assessmet that the leads ito formulatio which is about creatig hypotheses based o patiet eed ad admissio goals. Whe cosiderig chage, Prochaska ad Clemete s stages of chage model is a useful referece poit. Ask yourself questios such as i) is the team ready to take o board a chage i the way they collect/record data or to shift to a more obviously bio-psycho-social model? ii) If ot, what might be helpful i terms of brigig about readiess i terms of scaffoldig ad support. Where a team are accustomed to workig withi a medical model they ca feel axious ad uder-cofidet about implemetig a more psychological approach ot least because it ca trigger difficult persoal emotios precipitated by a more self-reflective respose. Takig time to support colleagues idividually or more practically settig up reflective practice groups ca be ivaluable. Eve though we kow that to formulate i a more bio-psycho-social way is good practice, axieties of idividual team members ca get i the way of this becomig a reality. Be cofidet i your disciplie, you are champioig psychology ad you eed to fly the flag for what psychology ca offer. Psychologists uderstad formulatio, relatioships, group dyamics, effects of stress at work, reflective practice, emotioal cotaimet, ad debriefig. Make sure others kow this repertoire of skills you could offer. Be midful ad sesitive to differet eeds ad how others idetify themselves; sigle sex wards ca assume various prejudices i geder idetity ad sexual orietatio. For a team to work psychologically, sigificat psychology time eeds to be ivested. Use the atioal guidace available to you to highlight why this matters, ad poit out the 75

80 problems of oly providig reactive, rather tha dedicated, psychology iput to the team e.g. icreased legth of stay, icreased use of atipsychotics ad so o. Do t just be grateful for beig give ay time o the ward, regardless of how limited it is. Make sure you ad key others are realistic i what you ca offer i the time that s fuded. Joi FPOP! There are a buch of supportive, similarly mided professioals out there, alog with useful documets ad a bulleti that you ca draw o i everyday work. Develop some sort of record (e.g. a ladder or diary) so that you ca record the small gais that you otice ad their relevace ad hold o to them at times whe you (ad others) feel overwhelmed by the scale of the task. Cosider sharig this with others so that there is a degree of trasparecy about your role ad the master pla! The itesity ad bubble-like ature about ipatiet work ca make it easier to be sucked ito the existig culture of uderlyig assumptios/espoused beliefs ad values tha i other teams. Make time to step back (escape the shared office for a coffee or a walk outside at least oce a day). Place yourself i a formulatio of what s happeig o the ward. Regular supervisio to assist you i this is essetial. I your formulatio iclude who is ad is ot beig give space to be heard: patiets, carers, professioal groups etc. Recogise that some/much of the work you do will ot look like what you ve bee traied to do. It does t make it less valid. Brief does t have to mea quick ad dirty. Drawig out the theory-practice liks i your thikig/actios will esure that you stay true to your professioal traiig ad practice guidelies. Do offer therapeutic itervetios. These short itervetios ca act as a taster of what is possible ad provide a useful sprigboard for later itervetios. What does t help? Do ot silo work. Workig i a ui-discipliary way will ot work. Your colleagues will ot uderstad your work, you will ot be adjustig your approach to what other disciplies are doig ad the service the patiet receives will be icosistet ad lack quality. Be cautious about havig a formal referral process ad try ad promote a coversatio. This ofte develops ito more of a cosultatio ad you ca decipher whether direct work with a patiet is appropriate. Promotig coversatios will allow you to educate your colleagues aroud what is most appropriate for psychology. Attedace i MDT meetigs ca be useful i this regard as you will hear a overview of the patiets ad recogise those who may beefit from psychology. Do t be shy about usig your title of Doctor. You might fid that Juior Doctors call you Doctor ad you are itroduced as such i meetigs with families. These dyamics ca be helpful i highlightig the promiece of psychology i ipatiet work ad your iput may be heard more as a cosequece. However, be aware of power dyamics withi the team ad the way your ow actios affect how you are perceived. These may iclude subtle hierarchies such as clothes wor, accepted seatig arragemets i meetigs or whether you are referred to as Doctor. Realise a balace betwee respectig yourself ad your professio with cofidece, beig dow-to-earth ad practical, ad ot overreactig to perceived slights i a hypersesitive way. 76

81 Challege but do t argue. Be patiet ad model emotioal regulatio ad appreciative styles of commuicatio to your colleagues ad patiets. Istead of public cofrotatio it is ofte more effective to speak to idividuals i private where they wo t feel humiliated or threateed ad likely safer to express their true fears or thoughts behid cliical decisio-makig. Do ot see psychiatry as the villai. It is ot. More ad more traiee psychiatrists are requestig supervisio from cliical psychologists to improve their kowledge of psychological models ad thikig. A respectful workig relatioship will eable true MDT workig ad this is whe the patiet really beefits. Do t try to do everythig at oce. Ipatiet work ca be overwhelmig with how much you might wat to support ad take o; see pieces of work through to the ed rather tha havig too may ope eded projects. Do t rush i without thikig through the support eeded to follow through with a project. Nurture colleagues adequately ad uderstad the barriers they face before you challege their practice. Techiques like demetia care mappig ca be experieced as puitive if the team experieces the exercise as highly critical ad does t feel it is empowered or resourced to chage. Do t rely o other people to record what you mea i the otes. Other colleagues might ot be familiar with the distictios we make ad the wordig of what you iteded might be very importat. Tips from our service user cosultatio group It ca be dautig ad frighteig whe you are first admitted ad you ca feel separated from your ormal self. It really helps if staff ca take time to kow you as a idividual. I would have liked to be able to talk to a member of staff every day. Make sure that you support staff to be able to help people who are i distress to begi to rebuild a meaigful sese of who they are ad who they wat to be. This is t always easy whe distress levels are high for various people withi the service (ourselves icluded sometimes) but it is the foudatio of what a psychologically health ward should facilitate. The most helpful iput is oe-to-oe. Do t let the admiistrative processes ad procedures cause you to lose sight of the importace of buildig relatioships i perso; with patiets, their families ad your colleagues. I would have liked to lear how to get aroud problems. This probably applies to everyoe o the ward. Do t get so hug up o feelig the eed to produce some very detailed big itervetio that you fail to offer the low level, basic psychological iput ad advice that ca help people feel cotaied ad show them a possible first step towards a way forward. Patiets felt that people stayig o a older people s metal health ward should have access to a cliical psychologist. It s a better feelig altogether whe you see a psychologist. 77

82 I would have liked to see a psychologist to discuss issues at the time. It would be useful to have dedicated psychology time, ad that it would be helpful for psychologists to model good practice ad offer traiig to support with the pressures facig frot lie staff. Use commets like this to remid those aroud you of the eed for psychological iput to the wards ad the positive reactio from patiets. Do t be shy about promotig the good work you are doig ad poitig to the people who value it. Help the team to thik about how to support families to make the best use of their time o the ward to maitai the relatioships that support the perso s wellbeig, idetity ad role. Cosider the preferred style of visitig (private room/public area/outside) ad remember that may families will feel axiety whe preparig to visit a ipatiet uit. This may be related to their relative s distress but also fear of the ukow eviromet. Buildig up family trust is importat. Self-care ad resiliece Iheretly, every ipatiet has bee deemed too uwell to be helped to recover with stadard commuity itervetios. Therefore, aticipate feeligs of impotece whe you approach cliical work. Though much is possible, it is a area that ca lack clear empirically defied guidace ad therefore requires practical ad iovative applicatio of valid kowledge ad priciples. Esure you have cliical supervisio with a supervisor who is a specialist i your area ad has a uderstadig of ipatiet work. You will likely take more of a supportive role to team members, so regular cliical supervisio is crucial to maitaiig your wellbeig ad cofidece. Keep i touch with your local etwork of psychologists ad peer professioal developmet etworks. The supportive ad differet poits of view offered are ivaluable i maitaiig your idetity ad ethusiasm ad ca be a cathartic forum to offload! Remai reflective ad take time to uderstad how the distress preset o the ward is impactig o you. Additioally, ackowledgig feeligs of frustratio ca prevet you actig o those impulses. We ca be great at lookig after others but self-care is crucial i beig effective, so urture iterests outside of work. Fially, take time to ejoy it. Ipatiet work is a area where may of us have bee part of sigificat positive chage ad bee able to work creatively to demostrate the value of our professio. So ca you. Leila Eccles 78

83 Cotributors ad ackowledgemets Editors: Kate Ross ad Sarah Dexter-Smith. Chapter authors: Ae Crawford-Docherty, Black Coutry Partership NHS FT, Sarah Dexter-Smith, Tees Esk ad Wear Valleys NHS FT, Kathry Dykes, Greater Machester Metal Health NHS Foudatio Trust, Fraces Duffy, Norther Health ad Social Care Trust, NI, Leila Eccles, Tamsi Fryer, Devo Partership NHS Trust, Gemma Graham, Rotherham, Docaster, ad South Humber NHS FT, Lee Harkess, Greater Machester Metal Health NHS Foudatio Trust, Clare Hilto, Humber NHS FT, Laura Kaye, Carolie Lamers, Betsi Cadwaladr Uiversity Health Board, Natasha Lord, Worcerstershire Health ad Care trust, Stephaie Petty, The Retreat, York, Nicola Robiso, Kate Ross, South Staffordshire ad Shropshire Health Care NHS FT, Richard Screeto, Ruth Watso, Paul Whitby. All authors are Cliical Psychologists other tha: Laura Kaye: Psychology Iter. Richard Screeto: Ergoomist workig i the uclear idustry. The followig orgaisatios provided thoughtful commet o drafts of this documet: Age Cymru Age Norther Irelad Joh s Campaig Royal College of Nursig Royal College of Psychiatry/CCQI Royal College of Speech ad Laguage Therapy Ad may FPOP members ad service users from across the four atios cotributed to the drafts of this documet as it progressed. Thak you to you all, we hope you fid the fial result useful. 79

84 The British Psychological Society St Adrews House, 48 Pricess Road East, Leicester LE1 7DR, UK Tel: Fax Website: REP116/11.17 Icorporated by Royal Charter Registered Charity No