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Implementing psychological approaches in the acute psychiatric care environment

The acute psychiatric care environment poses a number of challenges to those seeking to implement psychological therapy, and the evidence on whether therapy is feasible or useful in this setting has yet to be synthesised. One of the key goal of the Inpatient Applied Psychology Research Unit is to overcome these challenges and develop effective ways of helping people feel safe and supported towards a recovery that is meaningful for them. We have completed a number of studies to help us work towards this goal, and these are detailed below:

Lennon, Griffiths & Harper (in prep)

  • This was an uncontrolled evaluation of a six session emotion regulation skills group for patients receiving acute inpatient mental healthcare, led by Dr Ruth Lennon and supervised by Sean Harper. The group was an open, rolling group piloted over a 5 month period, with two sessions delivered per week.

  • Eight participants completed pre and post group ratings of emotion regulation, acceptance and distress.

  • Results suggested the intervention is feasible and acceptable, with preliminary evidence identifying potential clinical benefits.

  • Recruitment for this trial is complete, and the results (available here) are currently being prepared for publication.

Paterson, Karatzias, Dickson, Harper, Dougall & Hutton (under review)

  • The effectiveness of psychological therapies for those receiving acute adult mental health inpatient care remains unclear, partly because of the difficulty in conducting randomised controlled trials (RCTs) in this setting.

  • The aim of this meta-analysis was to synthesise evidence from all controlled trials of psychological therapy carried out in this setting, and examine whether the presence of randomisation and rater-blinding moderated estimates of effect.​

  • Overall, the results suggested psychological therapy was associated with small to moderate improvements in psychotic symptoms at end of therapy but the effect was smaller and not significant at follow-up. Psychological therapy was also associated with reduced readmissions, depression and anxiety.

  • The use of single-blind randomised controlled trial methodology was non-significantly associated with reduced benefits on readmission and depression, and significantly associated with reduced benefits on psychotic symptoms.

  • Whether this is a consequence of these trials having increased internal validity or reduced external validity is unclear.

  • We conclude that trials with both high internal and external validity are now required to establish what type, format and intensity of brief psychological therapy is required to achieve sustained benefits in this setting.

Paterson, Harper, Dixon, Hutton, Dougall & Karatzias (under review)

  • The primary aim of this controlled (non-randomised and open) trial was to test the feasibility of implementing and evaluating a cross-diagnostic, psychological intervention in an acute mental health inpatient setting in order to inform a future definitive trial of effectiveness.

  • A secondary aim was to gather exploratory clinical outcome data, likely to be used in a larger trial, and estimate treatment effects.

  • 96 psychiatric inpatients received either psychological therapy plus usual care or usual care alone.

  • The results suggest that some aspects of the trial were successful, i.e. clinical outcomes had good completion rates at pre- and post-intervention, some intervention components were successfully implemented (e.g. individual therapy) and some promising group differences were observed on some outcomes (e.g. overall psychological distress and somatization at post-intervention, and functioning and self-efficacy at follow-up). However, other aspects of the trial were problematic and need refinement to fully implement the intervention in real world settings and progress to a full trial.

  • Key issues identified in this study include problematic eligibility criteria, poor implementation of some intervention components, poor engagement, poor completion of follow-up questionnaires, and therefore poor trial retention.

  • Furthermore, the intervention was not associated with clear group differences in the primary outcome, namely a reduction in the proportion of those readmitted.

Stenhouse & Harper (ongoing).

  • This study is a qualitative exploration of staff experience of applying a psychological model of care to an acute inpatient setting.

  • It is hoped the findings will shed further light on the potentially modifiable barriers to implementation of this approach.

One of the main components of the psychological therapy approach we have evaluated is the teaching of emotional regulation skills. We have been actively investigating the role of this particular skill in causing and maintaining acute psychological distress.

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