Reflections on 50 Editions of Clinical Psychology Bite-Size

Key points

• Trauma and adversity are significant factors in mental health issues
• Power is key to understanding the cause of people’s difficulties and the potential to overcome them through access to resources and supportive relationships
• Making sense of experiences such as fear, sadness and madness is important. Bite-size has advocated for models beyond those which locate the problem inside the person
• Clients can experience services as supportive and nurturing, or as controlling and coercive. The latter may mirror and trigger previous experiences of disempowerment.
• Supportive and therapeutic conversations with clients are important as are positive connections to peers                                                                                          

Liberation Psychology

Key points

• Liberation psychology is a framework for taking account of how people and communities are shaped by their experience and history of oppression.
• Oppression results from an unequal society where social structures based on differences of race, gender, and class disadvantage large numbers of people
• Psychological distress is understood not solely in terms of the individual’s immediate circumstances but in the context of these wider social structures and injustices. 

Anxiety and Social Factors

Issue 49 – March 2017

Author: Bob Diamond (robert.diamond@nottshc.nhs.uk)

Key points

• Anxiety, along with other mental health difficulties, are frequently caused by traumas in earlier life and socio-economic difficulties, such as poverty, poor housing and living in impoverished environments.
• Anxiety appears to be on the increase in the Western world and this increase may well be influenced by the mismatch between social expectations on how we ought to live and the reality that we confront.
• Increased anxiety typically leads to an increase in arousal and awareness. Responses to heightened anxiety include, fight, flight and freezing (passivity, submission). 

The Value of Values

Issue 48 – November 2016

Author: Phil Houghton (philip.houghton@nottshc.nhs.uk)

Key points

• Values are chosen life directions which can provide an important springboard to behaviour change
• The ability to enact our values is heavily influenced by our social historical context

Understanding Biology in Adult Mental Health

Issue 47 – April 2016

Author: Steven Coles (steven.coles@nottshc.nhs.uk)

Key points

• There are differing views as to the importance of biology in causing mental health issues
• Staff tend to favour biologically based models, the public psychosocial
• There is no firm evidence base for biology being the primary cause of mental health issues
• Biology’s importance is in enabling what we do, rather than necessarily causing what we do.

Risk and Mental Health Practice

Issue 46 – December 2015

Key points

• Risk management dominates mental health practice.
• Current approaches to risk assessment limit a full understanding of threats to a person’s safety as well as inhibit recovery.

Inequality and Mental Health

Issue 45 – September 2015

Key points

• Inequality has been increasing in the UK for over 3 decades
• Greater inequality is related to increases in mental health and community problems
• There are concerns that austerity policies have increased: humiliation and shame; fear and distrust; instability and insecurity ; isolation and loneliness; and powerlessness

Early Childhood Experience and Adult Emotional Regulation

Issue 44 – May 2015

Key points

• The first few years of a child’s life are particularly important for a child to learn to regulate his or her own emotions and behaviour
• The architecture of the adult brain is less adaptable although changes are still possible

‘Loitering with intent’ on different stories

Issue 43 – February 2015

Key points

• The ideas or stories that we hold about ourselves provide the scripts from which we act
• There are countless other stories that we can tell about ourselves (and others)
• Helping individuals and families to tell different stories about themselves creates possibilities for alternative ways of acting and being

Negative Physical Effects of Psychiatric Medication: Self-identities

Issue 42 – November 2014

Key points

• Identity is important to us all. Physical appearance, gender and our social roles are important characteristics that help determine identity. These are all susceptible to the negative physical impacts of psychiatric medications
• Common negative physical effects that can impact on identity include sexual dysfunction, weight gain, hormonal changes, increased salivation, and urinary incontinence

Making Sense of Psychiatric Drugs

Issue 41 – September 2014

Key points

• Service users’ experiences of taking psychiatric drugs are varied, but often ignored
• Evidence for the chemical imbalance theory of psychiatric drug action is weak
• An alternative ‘drug model’ views psychiatric medications as working in a similar manner to other non-prescription drugs such as alcohol, and highlights the subjective experience of taking medication

Power and decision making on acute wards

Issue 40 – July 2014

Key points

• Recent research by the Values MIN provides evidence that neither service users, carers or healthcare workers feel there is currently shared decision making on the acute wards.
• The current ward round structure is not fit for practice.

Intervention and Dialogue with Families

Issue 39 – June 2014

Key points

• A robust evidence base has been established for Family Intervention with psychosis in research settings, however, questions have been raised about how this can be transferred into day to day practice
• The Open Dialogue Approach illustrates the potential for routine mental health care to be based on family-centred models for people with a label of psychosis

 Implications for practice

• View families as a potential asset and resource
• Recognise that family interventions for psychosis vary in content and approach
• Draw on an approach that fits with the family’s needs and preferences
• Seek to engage in dialogue rather than impose ideas

Open Dialogue I: Introduction

Issue 38 – April 2017

Key points

• Open Dialogue focuses on developing dialogue within a social network
• Experiences labelled as psychosis are seen as having meaning
• Research shows Open Dialogue has very good outcomes in Finland

Trauma and Psychosis: What Has Happened to You?

Issue 37 – December 2013

Key points

• There is a growing body of research recognising that a range of traumatic circumstances are a cause of experiences labelled as psychosis or schizophrenia.

The Complexity of Responsibility

Issue 36 – September 2013

Key points

• People often do not know why they act the way they do
• A judgement of responsibility can limit how we understand a situation and its complexity

Diagnostic and Statistical Manual of Mental Disorders 5

Issue 35 – May 2013

Key points

• There are increasing concerns that understandable reactions to traumatic situations are being pathologised
• Many studies highlight a financial conflict of interest between those involved in forming diagnostic categories and the pharmaceutical industry

Critique of the Evidence Base for Mental Health Treatments

Issue 34 – February 2013

Key points

• Randomised Control Trials (RCTs) are considered the ‘gold standard’ for research, and clinical guidelines are based on the findings of these studies. However, RCTs have a number of disadvantages
• A vast literature exists highlighting the importance of non-specific factors, such as a good therapeutic relationship, over the choice of treatment modality 

Collaborative Decision Making

Issue 33 – December 2012

Key points

• Collaborative decision making requires forming a shared understanding of an issue
• Different professionals and service users can have assumptions, values and goals that are in conflict with each other
• Legal, organisational and professional forms of power can inhibit equality in decision making 

Is insight enough?

Issue 32 – October 2012

Key points

• The aim of most therapies is to increase insight
• Insight focuses on the individual, ignoring important external factors. The concept of outsight (looking outwards to the wider world) is a useful alternative
• Insight as a concept may vary across cultures. We need to bear in mind cultural attributions of mental illness when defining insight
• Psychotherapy and psychiatric practice are cultural practices, which contain Western assumptions and values 

The role of language in mental health

Issue 31 – July 2012

Key points

• Language does not simply reflect the way events are, but shapes the way we see and experience them.
• The language we use serves particular functions (e.g. blaming, justifying).
• The terminology used to make sense of emotional distress is very powerful, and greatly influences how service users see themselves.
• Some ways of talking about distress are more stigmatising than others. For instance, labelling someone’s personality as ‘disordered’ is likely to be shaming.

Compassionate Mind Training

Issue 30 – May 2012

Key points

• Compassionate Mind Training is a therapeutic approach designed to enhance compassion
• Compassion is seen as the cornerstone for developing happiness and a meaningful life, but we need to be more modest with regards to its impact.

An Alternative to Challenging Unusual Beliefs

Issue 29 – November 2011

Key points

• Beliefs deemed unusual hold some form of meaning and function for people
• We all hold beliefs that cannot be proven or that parts of society might disagree with
• Challenging a person’s beliefs carries the risk of leaving a someone feeling criticised, shamed and could lead to disengagement from services 

Ethics in Clinical Practice: What’s the right thing to do?

Issue 28 – July 2011

Key points

• Within clinical practice we are often faced with the question “what’s the right thing to do?”
• Whilst we can not guarantee making the “right” decision, ethical frameworks exist which can help us make decisions in the right way 

Diagnosis of Personality Disorder

Issue 27 – April 2011

Key points

• Research has shown that the diagnosis of borderline personality disorder is stigmatising
• The diagnosis can be seen as a moral judgement rather than a scientific or medical concept
• People given this label have often experienced abuse, trauma and disordered environments

Employment and Mental Health

Issue 26 – January 2011

Key points

• Employment influences community well-being and individual levels of distress.  
• Fair wages and meaningful work are as important as whether someone is employed or not.
• Poor or financially inadequate employment has similar negative psychological effects to unemployment.
• Adequate employment is important as it reduces poverty and provides a daily structure and collective identity.

Growing up in care: implications for adult mental health

Issue 25 – November 2010

Key points

• Looked after children have commonly experienced abuse or neglect in their birth families and have lacked safe and responsive relationships with caregivers
• Even after leaving their birth families and entering care, children do not necessarily receive care which meets their needs and may continue to experience rejection and instability
• These experiences are likely to have an ongoing impact on people who have grown up in the care system and are likely to contribute to mental health problems in adulthood.  

Psychosis in Early Motherhood

Issue 24 – September 2010

Key points

• Women are particularly at risk of mental health problems in the time after childbirth
• Psychosis in this time is predominantly understood as caused by biological and hormonal changes but could also be understood as driven by the significant life changes and experiences that occur prior to, during and after childbirth
• Childbirth is a time of many social expectations and pressures, with the expectation of being a time of fulfilment, joy and development of the bond between mother and child.
• Mental health problems do not fit the social ideal of motherhood as a time of fulfilment  

Acceptance and Commitment Therapy

Issue 23 – July 2010

Key points

• The Acceptance and Commitment Therapy (ACT) model argues that much suffering is caused by trying to avoid or control painful experiences.
• ACT focuses on helping people to accept their painful experiences, choose valued directions in life and take action towards those values.
• A criticism of the ACT model is that it pays little attention to people’s social context and the inequality that means some people experience more aversive and painful events than others, and also have less resources to address these difficulties. 

Contextualising Distress III: Therapeutic Conversations

Key points

• Therapeutic conversations occur informally and in more formal settings.
• Therapeutic conversations should always be collaborative and involve a shared exploration of meanings and circumstances, so to make sense of experiences. 

Contextualising Distress II: Formulation and Practice Plan

Authors:  Bob Diamond and Steven Coles (robert.diamond@nottshc.nhs.uk and steven.coles@nottshc.nhs.uk) 

Key points

• Personal history and social context are central factors to understanding and supporting people who are distressed
• Formulation can highlight a distressed individual’s perspective and their context. However, formulation can be problematic if expert driven and imposed upon a person.
• In supervision formulation may support staff reflection, but added care is needed to consider the perspective of the person within services 

Contextualising Distress I: Background and Power-mapping

Issue 20 – January 2010

Author: Steven Coles (steven.coles@nottshc.nhs.uk)

Key points

• There is evidence for all forms of distress being shaped by a person’s social world and life experiences
• The limited attention to the context of people’s distress has led to power being concealed
• Rather than understanding power as residing within a person, power can be seen as acting between and through people.

Understanding and Working with Self-Harm

Issue 19 – November 2009

Key points

• Self-harm is a way of coping with difficult feelings and situations and is therefore considered a survival strategy
• People who use self-harm often report being stigmatised and labelled in unhelpful ways by health services. Paradoxically this maintains self-harm as it reinforces their negative view of themselves and the belief that they are unworthy of the support of others, or that others cannot or will not help them, and ultimately will reject them

Adult Attachment and Mental Health

Issue 18 – September 2009

Key points

1. Attachment Theory concerns the way we relate to others. It includes a person’s view of themselves as deserving of support and whether others are able to meet their needs.
2. Insecure attachment is linked to mental health problems. Such insecurity can be developed through childhood trauma, adversity and neglect.
3. The coercive aspects of services may limit their ability to provide safe, trusting relationships to service users and impact on our ability to meet their attachment needs.

Making Sense of Paranoia

Issue 17 – August 2009

Authors: Steven Coles (steven.coles@nottshc.nhs.uk) and John Cromby (j.cromby@lboro.ac.uk)

Key points

• Suspicious and paranoid feelings and beliefs are on a continuum with ‘normal’ experiences.
• Victimisation, discrimination and lack of power in the world appear to be causes of paranoia.
• Unusual beliefs are likely to reflect important themes or thwarted goals in a person’s life.
• Difficult social experiences can lead to shameful, angry or fearful feelings. Mixtures of these feelings can shape perceptions of the world and give rise to paranoid beliefs.

User Involvement

Issue 16 – July 2009

Key points

• User involvement at all levels of mental health services significantly contributes towards a more informed and personally meaningful understanding of distress.
• User involvement improves the effectiveness of care and support provided by Mental Health services by promoting a shared dialogue between workers and people who use services.
• There is a huge variation nationally of user involvement within Mental Health services, the debate continues as to whether real influences on services can be achieved through user involvement being situated within or outside of services.

Medication Groups

Issue 15 – June 2009

Key points

• Many people feel they have little influence over making decisions about their psychiatric medication.
• It is important for people who take, or are thinking about taking psychiatric medication to feel supported in asking questions about medication, finding out about alternative ways of coping with distress and accessing relevant and understandable information. Medication groups are one way of facilitating this.

Social Ranking Model of Distress

Issue 14 – May 2009

Key points

• Social ranking theory emphasises the importance of social relationships to our well-being
• People who are unable to escape difficult circumstances (e.g. domestic violence, difficult neighbourhoods etc) are likely to be distressed (including feeling ‘depressed’)
• Difficulties in a person’s early environment can also lead to a person having low self-worth  

Cognitive Behavioural Therapy for Psychosis

Issue 13 – April 2009

Key points

• We need to adopt a more modest and questioning view of CBT for psychosis, as whilst it can be a helpful approach the evidence base is not as strong as is sometimes suggested 

Understanding Voices

Issue 12 – March 2009

Key points

• There are a number of ways to make sense of the experience of hearing voices
• For some people and cultures hearing voices is viewed as a gift
• The experience of voice hearing is shaped by a person’s social world and personal history

Sexuality and mental health

Issue 11 – February 2009

Key points

• Historically sexuality and mental health has been viewed negatively, and service users are often pathologised as either asexual or deviant.
• Sexuality is not routinely addressed with service users, despite the focus on holistic care and research suggesting that sexuality is an important part of self.

Families and Psychosis

Issue 10 – January 2009

Key points

• There have been different understandings relating to the causes of psychosis, and these have been echoed in therapeutic approaches to working with families.
• Families are one amongst many complex factors that influence well-being (positively and negatively). Therefore we need to consider family influences when thinking about the cause and maintenance of distress.
• A family’s social context and access to material and social resources is likely to influence the distress of each family member.

Values Based Practice

Issue 9 – December 2008

Key points

• Values Based Practice (VBP) stresses that clinical decisions are not just about “evidence”, but are influenced by the differing values people have
• The strengths of VBP are that it argues that the service user perspective should be the start of any clinical discussion and highlights the weaknesses of Evidence based Practice
• The major weakness of VBP is that it fails to acknowledge that the people involved in any decision may have vastly different amounts of power to influence the outcome 

Community Psychology

Issue 08 – November 2008 Author:  Bob Diamond (Robert.diamond@nottshc.nhs.uk) 

Key points

• Community psychology primarily emphasises social influences on well-being and distress
• It advocates values such as respect, equality and justice
• It promotes preventative work that addresses racism, sexism and all forms of discrimination

Childhood Trauma and ‘Psychosis’

Issue 07 – October 2008

Key points

• Research suggests that child abuse can lead to ‘psychotic’ experiences such as ‘hallucinations’ and ‘delusions’ later in life
• This research has caused debate and controversy particularly for biological and genetically oriented psychiatric practitioners
• The focus on childhood trauma should not mean that other difficulties such as poverty and racism are ignored when considering psychological distress 

Difficulties with Diagnosis

Issue 06 – September 2008

Key points

• There appears to be a continuum between what is deemed ‘psychotic’ and so-called normality, rather than distinct diagnostic categories.
• Unlike medical diagnosis in physical health, psychiatric diagnosis lacks clear physical markers (signs) and is reliant on what clients say and do (symptoms).
• Psychiatric diagnosis does not appear to reflect real or meaningful categories.
• Diagnosis of “schizophrenia” is a poor predictor of outcome (symptomatically and socially) and does not indicate response to specific psychiatric medications.

Understanding “Delusions”

Issue 05 – August 2008

Author: Christine Collinson (christine.collinson@nottshc.nhs.uk)

• The idea that delusions can be separated from non-delusional beliefs and are a sign of an underlying illness is controversial, as is the notion that they are a problem to be removed.
• Delusional or unusual beliefs may hold an important function and have meaning.
• What we consider to be unusual beliefs reflect life concerns and goals. 

Religious beliefs and working with psychosis

Issue 04 – July 2008

Author: Sarah Keenan (sarah.keenan@nottshc.nhs.uk)

• Professional training and practice guidelines are often vague about how to work with religious beliefs.

• Religious beliefs influence coping strategies and recovery, therefore it is important to feel comfortable to sensitively ask clients about them.

Being Therapeutic

Key points

• Therapy and therapeutic relationships are shown to be helpful for service users approximately 50-60% of the time, although some sources suggest the figure is lower.
• Many studies over a number of years looking at outcome in therapy have shown there are few differences between particular therapeutic models.
• Common factors in therapy such as, trust, warmth, understanding and acceptance may be the most effective factors in therapy.

Discrimination, Ethnicity and Psychosis

Issue 02 – May 2008

Author: Steven Coles (steven.coles@nottshc.nhs.uk)

Key points

• Evidence points to environmental factors rather than genetic / biological factors as the reason for the increased rate of psychosis in some ethnic minority groups. Social factors in particular have been put forward as likely.
• Encountering discrimination seems to be related to people experiencing ‘delusional ideation’ at a later time.
• Individual discrimination can be subtle as well as blatant. Subtle forms can be as psychologically damaging as more obvious forms.

Understanding ‘Psychosis’

Issue 01 – April 2008

Author: Philip Houghton (philip.houghton@nottshc.nhs.uk)

Key points

• The “illness” model of ‘psychosis’ is just one amongst many ways of understanding ‘psychosis’
• Social, economic, cultural, historical and psychological factors all influence the development and maintenance of psychotic experiences