What is Clinical Psychology?

Arlene Vetere, PhD

drarlenevetere@hotmail.com

A modern introduction to clinical psychology on the ground…..

• Delivering clinical interventions

• Supervision

• Consultation

• Leadership

• Training

• And research, in changing health and social care services

• The voice of the users of these services

A modern introduction……

• Using psychological theory and research to understand and help alleviate human distress

• Assessment, formulation, intervention and evaluation

• Different specialties • Range of work: direct/indirect; group work;

organisational development; service evaluation…….

• The therapeutic alliance • Multi-disciplinary teams

Multi-disciplinary teams

• Rationale

• Staff support, training and supervision, team development, team formulation, reflective practice sessions, leadership

• Team dynamics: competition, professional rivalries, different approaches to understanding and treating emotional distress, struggle to understand and value different perspectives

• Team effectivesness: role clarity and respect, shared goals and culture of care = creativity

Clinical psychology does not stand still

• Talking therapies and psychologically aware services are what the users of mental health services want, and need

• Active collaboration, trust and emotional safety

• Research evidence offers a clear mandate to expand the availability of psychological interventions

• Developing and delivering the best care requires competencies in research, teaching, supervision and consultation

Formulation

• Connections between assessment information and psychological theory and research: collaborative formulation

• Basis for decisions about helpful interventions • Progressive hypothesising: pre-disposing, precipitating,

maintaining and protective factors • Major models: behavioural, cognitive-behavioural,

psychodynamic and systemic • Empirically supported treatments, evidence-based

practice and practice-based evidence • Integrative practice

Behaviour Therapies

• Focus on overt and measurable behaviour

• Learning theories – classical and instrumental conditioning – positive and negative reinforcement, punishment

• Maladaptive anxiety develops through classical conditioning, maintained through instrumental conditioning ie avoidance

• Here and now focus – learn new associations – graded exposure, relaxation, stress innoculation training, behavioural activation, problem solving

Cognitive Behaviour Therapies

• Subjective thoughts/perceptions direct impact on behavioural and emotional state

• Psychological disturbance unhelpful ways of viewing self, world and future

• Cognitive processes accessible, so have potential to change them; meaning given to a situation determined by beliefs/schemas – also accessible to change

• By, learning to identify unhelpful beliefs, reviewing and testing alternate beliefs, possible to change beliefs serving to maintain and trigger symptoms

Psychodynamic Therapies

• Short term approaches

• Focus on ways in which emotional and relational dynamics set up in early life come to be replayed in ways that are unhelpful/give rise to psychological symptoms

• Early life experiences with caregivers give rise to internalised models and behaviours about what it takes/means to remain connected to that caregiver (AF)

• Adaptive in childhood – survival – in adulthood may interfere with trust and intimacy – repeating patterns

• Insight oriented – understand patterns, integrate experience into conscious awareness

Systemic Therapies

• Many different schools of systemic therapy

• Relationship dynamics and experiences give rise to psychological distress

• Significance of context, pattern and process

• GGRRAACCEESS

• Intervention with relationships

• Working ‘within’ and ‘between’

• Integrated formulation

Choice of Therapy

• Why might we choose an alternative intervention over an empirically supported treatment:

• Client informed choice

• Good attempts at previous EST not successful

• Problems of greater concern may best be addressed by a different therapeutic approach eg working with violence in relationships

Three Frameworks

• Scientist-practitioner

• Reflective-practitioner

• Critical-practitioner

Reflective practice

• Reflective practitioner: reflection in action; reflection on action – reflecting on learning, emotional responses, ideas and theories that guide action – insight for improved action in the future

• Continuing professional development

• Life long learning

• Reflective supervision

• Self of the therapist

• Taking care of ourselves and each other

Critical Practitioner

• Social constructionism – use of language: how it has maintained power and authority within and between professions

• Critique of psychiatric diagnosis versus formulation

• Recovery oriented practice and quality of life

• Social inequalities and relationship with well being

• Social exclusion and social connections

Scientist Practitioner

• Application of research evidence: randomised controlled trials (efficacy); effectiveness trials; case series; experimental research; cost-effectivesness research

• Credibility of the profession?

• Limitations of the evidence base

• Good reasons for choice of alternative therapy?

• Clinical wisdom – best available research evidence – client preference

Drawing on the three frameworks in clinical practice

• Good understanding of what works and the evidence base

• Tailor our approach to unique circumstances of client/family

• Avoid imposing own cultural values and worldview

• Create space to reflect on what we are doing and learn for the future

• Evaluate work on an ongoing basis using valid measures/feedback processes

The Bio-Psycho-Social Model

• Biological: genetic predispositions, neurochemistry, effect of medications, immune response; fight-flight-freeze responses, physiological responses

• Psychological: learning, emotions, cognition, memory, perceptions, beliefs, values, coping, biofeedback, exercise

• Social: social support; attachment and inter-personal relationships, cultural traditions, family and kin, poverty and discrimination, social class, faith, social and health care systems

Understanding Trauma Responses

• Fight, flight and freeze

• Brain systems involved in emotion regulation

• Dissociation and social isolation

• Social engagement system: non conscious relational responding; interactive regulation

• Addictions and self harm: attempts to cope with unbearable emotion and numbing

• Emotional safety in relationships

• Trauma changes brain development, self-regulation and capacity to stay focused and in tune with others

Helping with Trauma Responses

• What are people trying to cope with? • What are their internal/external resources? • How do they calm themselves down? • Do they have caring relationships with their own

bodies? • What do they do to develop a sense of agency,

vitality and relaxation? • Do they have emotionally salient interactions

with others? • Do they have a sense of purpose?

Helping with Trauma Responses

• Who really knows them? Listens to them? Loves them? Cares for them?

• Who do they turn to for comfort? • Who looks after them when they are ill? • Are they members of a community? • Do they play a vital part in the lives of the people

around them? • What skills do they need to focus, pay attention, and

make choices? • What are they good at? • How can we help them feel in charge of their lives?

Future Directions

• Understand and support communities • Help develop ‘healthy’ organisations • Enable teams and networks to promote

psychological well being • Recognise and work with the crucial role of

families and attachments in the development of emotionally robust communities

• Work with people with complex mental health difficulties who have not responded to psychological therapy

Future Directions

• Develop service initiatives to support the growing population of people with long term neurological and physical conditions, and their carers

• Develop supervision and reflective practice systems to help staff and services remain compassionate when they are under threat

• Produce research and training to help others advance knowledge of, and capacity to intervene in, all of the above

Some reading…..

• Davey, G., Lake, N. & Whittington, A. (eds) (2015) Clinical Psychology. Second edition. London: Routledge

• Dallos, R. and Vetere, A. (2009) Systemic Therapy and Attachment Narratives. Applications in a range of clinical settings. London: Routledge

• Johnstone, L. and Dallos, R. (eds) (2006) Formulation in Psychology and Psychotherapy. London: Routledge

• Van der Kolk, B. (2014) The Body Keeps the Score. Second edition. Penguin Books