Take Two Bottles Into The Shower? Not me, I’m a Clinical Health Psychologist by Ross Warwick

Because you’re worth it

Bang! And the dirt is gone!

Eat fresh

I’ve been thinking a lot about advertising these past few weeks as September is a significant time for my team in Clinical Health Psychology. This month we will be making a concerted effort to promote our service, raise our profile and increase our contact with the people we aim to help.

As part of this, Ken has kindly allowed us to take over the blog for a few weeks. I’m kicking things off with an account of what the service does and I thought I would take inspiration from psychological tricks used in the world of advertising to help draw you in and get the message out there.

I’ll start, then, with a summary of the service that follows the advice of a Professor of Experimental Consumer Psychology at the University of Wales, Jane Raymond. Prof Raymond advises that rather than bombard the audience with information I should break it into chunks to allow the brain time to process each component:

• Chunk 1: The Clinical Health Psychology service helps people who have a psychological problem that is caused and maintained by a physical illness.
• Chunk 2: These problems usually involve unpleasant feelings and unhelpful thoughts about the illness that keep someone from doing things that matter to them.
• Chunk 3: This can cause distress, affecting overall well-being, medical treatment, self-management and health outcomes

An article in a social psychology journal showed that a wide range of people respond well and are persuaded by stories (Thompson and Haddock, 2012). So to illustrate chunks 1-3 here’s a fictionalised case based on real events:

“Jane is a young teacher who has type 1 diabetes. Her condition and the things she must do to keep on top of it are often accompanied by feelings of shame, anger and loneliness. She has frequent thoughts that her condition means she is abnormal and that it must be hidden from others. Because of these unhelpful thoughts and feelings she avoids testing her blood, guesses her insulin levels, is inconsistent with her diet and keeps problems to herself.

She has been absent from work and in and out of the DGRI several times within the past twelve months. Because of this she believes friends, family and colleagues are annoyed with her for not taking proper care of herself and landing them with more responsibility. As a result, she avoids seeing people and has become more and more isolated.”

The next steps for Jane are chunked below:

• Chunk 4: In therapy we would work with Jane to live well with her condition by addressing her unhelpful thoughts, feelings and avoidant behaviour
• Chunk 5: As therapy is all about collaboration, Jane’s most likely to have a good outcome if she’s motivated to participate and make changes to her life
• Chunk 6: Jane can be referred to Clinical Health Psychology by anyone who is involved in her care, be it her GP, Practice Nurse, Dietician, Diabetes Specialist Nurse or Consultant.

In Jane’s story, she’s in and out of DGRI because thoughts and feelings stop her from acting in a way that would help keep her well. So psychological therapy would add value by reducing her distress and unplanned contact with services (and by highlighting that sentence your attention has been focused on a key message about how psychology makes a difference to both the person and the hospital; Pieters and Wedel, 2004).

But would you believe that individual therapy expertly delivered by members of our experienced, compassionate, and, yes, attractive, team is but one feature of our service? In Clinical Health Psychology we also provide training, teaching, supervision and consultation because you don’t need to be a psychologist to provide psychological care (worth mentioning because (a) it’s completely true and (b) according to Goodman and Irmak, 2013, audiences are likely to prefer multi-featured products).

Already the Diabetes and Cardiac Teams are benefitting from increasing their psychological knowledge and skill through participating in Emotion Matters training, and a group of local GPs have recently completed training to introduce CBT techniques into their routine consultations. Recruitment of a second cohort will be underway soon.

Time for pictures of the product:

By now thanks to my evidence-based and scientifically informed techniques of persuasion, you will no doubt want to know how you can benefit from working with our wonderful service.

You can contact us by email or by calling us at the psychology department to talk about matters psychological, be it complex cases, potential referrals, or training your department. Find out more about making referrals by consulting our service leaflets which are available absolutely FREE through Beacon by searching for ‘Clinical Psychology’ or looking under ‘Documents’ after following the link below. And as the Patient Information Leaflet can also be found there, you enjoy a 2 for 1 bonus!

http://hippo.citrix.dghealth.scot.nhs.uk/sorce/beacon/?pageid=Sitesearch&searchCriteria=clinical%20health%20psychology

Keep your eyes open for opportunities to attend training events we’re delivering this month and enjoy the blog posts written by the Clinical Health Psychology team over the next few weeks. Finally, to eke this advertising ruse out just a little further, comment below to be part of a Clinical Health Psychology virtual focus group.

Just do it.

Ross Warwick is a Consultant Clinical Health Psychologist and Lead for Clinical Health Psychology at NHS Dumfries and Galloway

Stressed about Stress by Amanda Taka

Stress is one of those words that has become intrinsic in our everyday vocabulary: we’ve all heard ourselves moaning “I’m so stressed!” What is it and how can we manage it?

Stress is defined in different ways by different organisations, but the common thread seems to be that stress is “feeling under pressure”. A small amount of stress is good for us: it keeps us motivated and helps us to do our best. However, when we are living with stress all the time, it can lead to a myriad of unpleasant feelings and physical symptoms can follow.

Often we are quick to identify stress in others, but would we recognise it in ourselves? Symptoms associated with stress are wide ranging and initially we might not associate the physical symptoms as related to our mental wellbeing. There has been a tradition to separate mental and physical health, but evidence shows the link is greater than we previously may have understood. The jury is still out as to whether stress itself causes disease, but there’s lots of evidence to show that the unhealthy habits we rely on when we’re stressed contribute to many conditions.

Physical symptoms can include:

• Sleep problems
• Dizziness
• Chest pain, palpitations
• Dry mouth, lump in the throat, shaky hands
• Lack of appetite, or conversely, comfort eating
• Repetitive tic
• Headaches
• Diarrhoea or constipation
• Loss of libido
• Tearfulness/depression/anxiety
• Worsening symptoms of long term conditions

Additionally:

• Poor concentration
• Difficulty making decisions
• Irritability
• A feeling that things are hanging over you
• Excessive intake of caffeine, cigarettes or alcohol
• Low self esteem/lack of confidence

This list is not exhaustive!

What causes stress?

Here’s the tricky bit. We’re all different, so we all have different triggers. For example, one nurse would struggle to cope with the incessant physical and emotional demands of working in the Emergency Department, whereas that environment is perfect for a different nurse.

Acknowledged triggers of stress are as follows:

• Work pressures, job instability, fear of redundancy
• Parenting, family and relationship difficulties
• Financial pressures
• Bullying and discrimination
• Loneliness and isolation
• Living with a long term condition
• Caring responsibilities

And one more for us workaholics:

• Taking on too much responsibility and feeling you don’t have enough time to do everything!

OK, so it looks like life itself is stressful.

If you’re feeling like stress is starting to impact on the quality of your life then the first thing would be to get it down on paper. Spotting stress in its early stages can help prevent things from getting worse. Things to include in your “stress diary”:

• Date, time and place of the incident
• What you were doing, before, during and after
• Who you were with
• What were your feelings, before, during and after
• Any physical sensations
• Give the event a “stress rating” e.g 0 = no stress, 10 = the most stressed you could possibly feel.

Making a stress diary is helpful because it aids our ability to make connections between the context and the symptoms. Ideally, a stress diary should be continued for at least 2 weeks. This helps us to see things in perspective. Additionally, this is a vital piece of evidence to discuss with your GP if you’re feeling overwhelmed and unable to cope.

Quick Fix

When I searched ‘wellbeing’ in Amazon at the beginning of the year, I was astounded at the number of different products that claim to enhance one’s wellbeing: necklaces, crystals and orthotic sandals sat alongside the list of ‘new age’ literature that was available. I’m not sure it’s something that can be bought. There’s certainly no single ‘cure all’ solution. Therefore it’s worth trying, or combining, a number of different approaches until you succeed. Most research shows the following are a good place to start:

• Physical activity – doesn’t need to be a gym membership, incorporating 30 minutes of activity can help boost mood and clear the mind (remember it can be in blocks of 10 minutes)

 

• Sleep better – ideas for improving your sleep can be found at http://www.nhsinform.co.uk/mentalhealth/wellbeing/stress-management/

 

• Relaxation techniques such as mindfulness and breathing exercises are evidence based ways of reducing stress. Courses are available across the region, check the local press or http://www.uws.ac.uk/wellnessandrecoverycollege for details.

Nursing is acknowledged to be a stressful profession. In our profession, we tend to put everyone before ourselves, but who looks after the caring professions? I passionately believe that we need to give ourselves the time and effort to look after our own mental wellbeing, and being aware of our stress levels is intrinsic to this.

Further self help resources to try:

• Living Life telephone self help service and online programme for people with mild to moderate feelings of anxiety and depression using Cognitive Based Therapy. See http://www.llttf.com/ for more info

 

• Breathing space – confidential helpline that describes itself as a ‘first stop’ service which aims to listen and provide emotional support. http://breathingspace.scot

 

• Moodjuice – a website designed to improve people’s emotional resilience and ability to solve problems. http://www.moodjuice.scot.nhs.uk/

 

• Steps to Deal with Stress – you may have noticed the little square booklets floating around NHS D&G, pick one up, they have great common sense tips to help with stress busting. More info at http://www.stepsforstress.org/

A last word

If you or someone you know is struggling and self help techniques haven’t worked, you may need to seek expert help. For some people a combination of medication, talking therapy alongside some of the techniques outlined above are appropriate. Also, it’s worth remembering that the Samaritans have changed their number to 116 123. Further helplines can be found at http://www.nhs.uk/Conditions/stress-anxiety-depression/Pages/mental-health-helplines.aspx

And remember… “taking on too many commitments” may lead to feelings of stress!

Amanda Taka is a Keep Well Nurse at NHS Dumfries and Galloway

Mental Health Change Programme by Ian Hancock

Government policy, changing demographics, epidemiology, health inequalities and increasing public expectations services, requires NHS Scotland to flex and bend to meet healthcare needs of the Scottish public.

The challenges faced by NHS Dumfries and Galloway Mental Health Service Directorate are no different from the national perspective, and have required innovative thinking which have seen the development of better ways of working.

The demographic changes facing Scotland are well documented, with the number of people in Scotland aged over 65 projected to increase by 22% by 2020, and by 63% by 2035. The over 75 population is predicted to increase by 23% and 82% over the same period and the over 85 population will increase by 39% by 2020 and 147% by 2035. Our current service will need to adapt to meet the healthcare needs of this growing population

We all recognise the benefits of keeping people at home, or within a homely setting, as close to their family, friends and local community. The Mental Health Service works closely with patients, carers, statutory and third sector colleagues to provide services that, wherever possible, prevent unnecessary hospital admission. There are, however, times when admission to a hospital is necessary and with this in mind, we have been developing our services over a number of years, and have seen a huge shift from hospital based care to community settings. We need to capitalise on our previous successes and have identified ways in which we plan to move ahead over the coming years.

The Mental Health Service Directorate comprises of four large component service teams (Mental Health, Learning Disability, Substance Misuse and Psychology) and within these teams there are a range of individuals from different professional backgrounds (nurses, AHPs, administrative staff, HCSW, Medical Staff, Psychology, and workforce business partners from Workforce Directorate, Finance). We have 2 in patient units based in Midpark, and in Darataigh in Stranraer, and have numerous community bases across all 4 localities

Over the next few years, the Mental Health Directorate will continue to strive to provide care that aligns with contemporary healthcare policy and legislation, and do this in a collaborative way with our stakeholders. In order for us to ensure appropriate services are being delivered, and that will meet the health needs of the general public of Dumfries and Galloway, we will continue to focus on a number of specific areas.

We will consider ways in which our inpatient beds are configured and consider opportunities to improve individual’s experience of in patient care, whilst developing inpatient services in line with our changing demographics. Services will be based on patient need rather than age.

We will support and evaluate the current 24/7Crisis Assessment and Treatment Pilot Service (CATS), based in the Out of Hours/Accident and Emergency Unit

We will develop our IDEAS (Interventions for Dementia, Education, Assessment & Support ) Service, a team designed to enhance skills in statutory and non statutory services specifically for individuals with a diagnosis of dementia.

We will develop a model of care that takes into account the challenges associated with our more remote and rural areas.

We will develop services which provide early interventions for people with memory problems, and develop Health Care Support Workers to work with families living with dementia.

This is an exciting time with significant challenges to face. We think, however, that we can offer a modern and effective service, within budget, but that such successes will inevitably rely on continuing to build strong working relationships with our service users, carers, and families, colleagues from all health and social care settings, and third sector partners.

Ian Hancock is the General Manager for the Mental Health, Learning Disability, Substance Misuse and Psychological Services Directorate

Having a bad day? by @kendonaldson

Are you having a bad day? Or has the day just begun and you are struggling to face it – you know the ward is full but you have 8 admissions and no one knows where to put them. Perhaps you have 6 meetings lined up and you know that all will be challenging with little achieved. Or maybe you have a ward round then a clinic and you already have 50 unopened emails and no prospect of time to deal with them except when you get home later tonight. And on top of this your Dad is sick, or maybe your partner has just lost their job or your child is struggling in school. Sound familiar?

Very few of us come to work with absolutely no worries and even less of us find our days work problem free. We all react and behave differently to these stressors. Some thrive on them and perform even better than expected. Others struggle and this often becomes apparent from day to day. I know I struggle and often I don’t quite realise it but I do have a few ‘barometers’ that tell me things are getting bad. People say things like:

“You’re sighing a lot Ken”

“I heard you sighing from the end of the corridor”

“You’ve just arrived and you are sighing already!” (Sighing features quite a lot)

I saw you walking down the corridor and your head was low and your face was miserable. What’s up?”

“Ken, you were a bit short with them.”

And, probably most telling of all…

“Daddy, why are you so grumpy?” Sadly, sometimes said through tears.

Its when I hear phrases like these that I realise its time to take stock and focus on what really matters to me: my family, my friends and doing the job well, not rushing things and upsetting people.

I recently read a bit of advice from a psychologist. She holds a glass of water and asks her students how heavy it is. There is a range of answers but the point isn’t the absolute weight, its the fact that as she holds it longer and longer her arm begins to ache as the glass feels heavier. Ultimately her arm is almost paralysed in pain. Anxiety and stress are a bit like this. The longer you think about something the heavier it becomes until eventually you are paralysed. You need to put the glass down every now and again.

The reality is that working in the NHS is tough. We are short on doctors, nurses, beds and the patients keep on coming. Paperwork changes or the number of forms increase, new IT that seems to hamper rather than help, wards are shut due to norovirus or flu. GP numbers are so low that practices are covering ever increasing areas and more patients. The list goes on but it affects almost all of us.

So why this blog? Well it’s to ask us all to remember that it may not just be you having the bad day. It may be your colleague on the other end of the phone, or the other side of the bed or the other side of the table. They may in fact be having a worse day than you. If we remember this, are kind and considerate to each other and consider that we are actually all on the same team then it might make our day a little better. Random acts of kindness, however small, can make a difference: saying thank you, making a cup of tea, a smile.

At the end of the day it’s not just you or your colleagues who lose out. It’s also the patient and, chances are, they are having a significantly harder day than you!

Ken Donaldson is a Consultant Nephrologist and Associate Medical Director at NHS Dumfries and Galooway.

What are you doing? by Ross Warwick

If there was a camera trained on you right now like in Big Brother or The Truman Show, transmitting to televisions and tablets up and down the country, how would the audience see you behaving? Take a moment to notice what it is you’re doing. Are you sitting or standing? Are you mutli-tasking, trying to read this whilst having a conversation with a colleague? Are you tapping an NHS biro on the desk or drumming your fingers? These things that you are doing, whatever they may be, are behaviours.   

So if I was watching a monitor, observing that live broadcast of you reading this blog, I might make informed assumptions about why you were acting as you are. I might guess that your decision to sit or stand is perhaps motivated by a need to be comfortable; multi-tasking might illustrate a wish to get as many things done as possible; and drumming your fingers and tapping your biro might be impatience that I have yet to get to the point (SPOILER: you may be expecting too much…).

It’s not just psychologists who make assumptions about the behaviours of others; everyone does it. To help us make our judgements it’s likely we would call upon other contextual information. This might include the things we already know about that person, our previous contact with them, things we know are going on in the environment around them, their personality and so on. Furthermore, the conclusions we reach are filtered through our own particular view of the world and our mood at the time.

Behaviour can be a rich source of information. Analysing behaviour can be of significant clinical value because all behaviour happens for a reason. It serves a purpose. If a behaviour didn’t fulfil a particular need then you wouldn’t do it. If by pressing a certain button on a broken vending machine you got a free Mars Bar then you would repeat the behaviour again and again. Once the machine had been repaired your frantic button tapping would stop (although only after a few bonus taps for good measure, just to be sure).

Considering behaviour and the needs it may be fulfilling is one of the central tenets of therapeutic approaches such as Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT). In this context we are interested in the things that people do that are detrimental to their long-term well-being. In mental health that might be a depressed young man who doesn’t contact his friends or an anxious lady who has stopped going out. In these two cases the behaviours of interest serve an important purpose: they protect against harm. The young man is protected from his belief that no one wants to spend time with him because he’s boring; the older lady is protected from anxiety about falling over and injuring herself. Their actions have a clear logic when the reasoning behind them is explored.

In physical health the behaviour of interest may not be related to a mental health problem. Consider a patient who is at ease with a diagnosis of kidney disease.   However, they have not taken on recommendations regarding dietary and fluid intake, putting them at risk. So the behaviour here could be characterised as a failure to follow advice that would improve their physical health. See also a patient with COPD who continues to smoke; someone with Type I Diabetes who doesn’t monitor their bloods; the drinking habits of someone with liver disease.

It can be hard to comprehend such behaviours when the stakes are so high but there will be needs underlying them nevertheless. I would wager that most of us have tried to change our behaviour in order to improve our health and relapsed into old habits after a few weeks. I bet too that when quizzed there were a whole range of sound reasons why. Personally, I couldn’t find the time to keep running, plus my ankle was hurting. And it’s not safe to run in the dark round where I live. And the routes aren’t varied enough so it was boring. Look, just back off will you?!

In some cases the need to change is a priority for those involved in providing care, not the patient themselves. This might mean that our behaviour towards them will change as a result, driven by our own needs to make sure they keep well. If you were in such a situation and there was a camera trained on you, what might we see?

Attending the Emergency Department is a behaviour that fulfils an important need; to seek urgent medical attention. Patients who frequently attend also do so to fulfil a purpose but the reasons are sometimes complex and difficult to discern. I’m involved with a project in A&E designed to help understand why people frequently attend. This understanding leads to the development of management plans that colleagues can use to ensure patients receive the treatment that they require. We use the formulation below to help:

 

Figure 1. Formulation model (based on James et al, 2006)

So how are you behaving just now? If you were seated are you standing? If you were multi-tasking are you now just reading? If you were restlessly tapping are you now still and calm? If so I choose to interpret your behaviour as evidence that my blog has succeeded in engaging you. Please feel free to challenge my assumptions in the comment box below.

Dr Ross Warwick is a Clinical Psychologist and Neuropsychologist for the Physical Health and Psychology Service at NHS Dumfries & Galloway