Clinical Health Psychology

Dr Suzanne Carson

Consultant Clinical Psychologist

What is it?

The application of the scientific principles and theories of psychology to patients with physical health problems and/or disabilities who develop serious difficulties in coping with their ill health or its impact on their lives

These difficulties may have an impact on the patients illness, treatment, recovery and prognosis

Who do we see?

Acute problems Chronic problems

Acute Needle

phobia,claustrophobia and other anxiety problems which can impact on treatment eg MRI scan, blood tests etc

Screening prior to an elective procedure eg amputation, plastic surgery etc

Chronic Renal problems, chronic

pain, any condition which is long term

Current Areas of intervention

Chronic pain – PMP Rheumatology Cardiology Dermatology Oncology Respiratory medicine Renal – incl

transplant

Diabetes Orthopaedics Genetics Rehabilitation –

spinal injury, amputee rehab

neuropsychology

Aim of Service

Provide some combination of psychological assessment, guidance and treatment towards managing illness, coping with illness or adjusting to illness

Clinical Health Psychology

Train as Clinical Psychologists Specialise in clinical Health Psychology Specialist Interest group within BPS

Local Work

Belfast City Hospital, Royal Victoria Hospital, Musgrave Park Hospital. Dundonald Hospital. Craigavon Area Hospital, Altnagelvin, Antrim, Coleraine. Londonderry Area

Work in patients, outpatients, hospital and Community

My own Path

Qualified 1993 from QUB Worked in BCH until 2006, Pain

management programme, dermatology,trauma and orthopaedics etc

Moved to MPH rehabilitation services, specialised in spinal cord injury and amputee rehabilitation services

Musgrave Park Hospital , Belfast

The world of Rehabilitation

What is Rehabilitation?

A continuous process, begins at moment of injury

A process of active change by which the person can acquire the knowledge and skills for optimal physical, psychological and social functioning

What causes amputation

Diabetes Vascular disease

Tumour Trauma eg, accident

at work, crush injuries, road traffic accident

Amputee Rehabilitation

8 bedded specialist unit in MPH Amputees come for specialist rehab incl

prosthetic fitting and gait retraining Majority lower limb, some upper limb Adults and children(mainly genetic,

some tumour)

Psychological issues

Pain, esp phantom pain Body image Interruption of life goals Loss of independence Body image/relationships Adjustment to disability Post traumatic problems

New developments

Specialised limbs for specific activities, water limbs for water activities, cycling, playing instruments etc.

New highly developed ‘bionic’ limbs esp for hand/arm ampiuees whose fingers move and grasp individually etc.

Specialised training courses eg, running with blades

SCIU Musgrave Park

15 bedded unit Average stay 4-6months Mixture of tetra/para/GBS 1 fully ventilated patient Age 16+ Pressure Sore Management

The Team

Consultant in Rehab Medicine 3 PT’s/3OT’s 2 SW Dietician Clinical Psych Nursing SIA

Aetiology, incidence and prevalence

47% RTA 27% domestic falls 15% sporting injuries 5% self harm 0.5% acts of violence Non traumatic – infective disease

neoplastic disorders, MS, GBS, etc

4:1 male to female Mean age 28 but increasing 10 – 15 per million per year in UK Life expectancy – young incomplete =

96%survival, complete tetra over aged 50 -33%

Pneumonia, p.e, septicaemia

The Aims of Rehabilitation

Issues Affecting SCI Patients in hospital Lack of privacy Lack of independence Changes to role Uncertainty re future Helplessness Separation Inability to control bodily functions

Psychological Complications

Psychiatric diagnosis – substance abuse, suicide

PTSD Depression – affects rehab Neuropathic pain – often associated

with depression

Psychological care pathways

Initially conveying sense of safety – that sci and its consequences are manageable

Collaborative framework – construct new reality that is helpful and credible, CBT, Goal planning

Individual work Interventions with families Group Coping Effectiveness Training

Ways of working

Individual work – inpatient or outpatient Family therapy Couples work Staff work Patient education Family/carer education Research/training

Issues in rehab

At times physical health concerns come first, psychological issues may not emerge until later

Many will premorbidly have been psychologically very stable, others may have had difficulties before.

Final thoughts

Challenging rewarding work Pick up lot of medical/technical

information Working in hospital has its own

challenges Close team work Small, developing specialism, research

opportunities++

Respiratory Medicine

 Bethany a 21 year old student at University has lived with difficult asthma all her life.  Throughout her life she would have several hospital admissions due to her problems breathing. However last year she was admitted to hospital struggling to breathe and had to spend several days in ICU.  She has flashbacks and nightmares to her time in ICU.   

Resp.

She feels very anxious and is overusing her medication for fear of having another asthma attack.  She is very tearful and is falling behind with her course work.  She is referred to Clinical Psychology.

The focus of sessions is to give Bethany space to talk about what happened to her in ICU and her fears for the future.  She is very tearful in the sessions.  We use a technique in therapy called EMDR to help her adjust to the traumatic memories of ICU.  After several sessions the nightmares and flashbacks settle and her mood improves.  We close the case as she made good progress.

 

Trauma Case - orthopaedics

Outpatient referral by consultant 5 months after a serious work injury event as felt that Peter was “rather down” after the event. GP had already prescribed antidepressants.

  Peter 46 years old was a supervisor in a factory, hit

by a piece of equipment with no warning 6 months ago. Emergency hospitalisation and surgery required including transfusions for blood loss.

Injuries were multiple mainly lower body on left side including pelvis, femur, knee and ankle fractures. Went to theatre 3 times. Hospitalised for 6 weeks (including no weight bearing for 4 weeks). Recalls “constant pain” whilst in hospital.

 

Peter- information from initial assessment.Peter is married, 2 children (1 at university 1 at school)Wife works part time as a nurse Peter is mobilising without any aids, ankle and knee injuries still cause pain and reduce type and amount of activity at times. He is recommended to use swimming and walking. No restrictions on his activity have been recommended. He gets sore during and after activity. Peter cannot return to work until he is safe to be in a factory environment.

Peter described his problems as not being able to get back to normal i.e. work, activities with family and emotionally feeling weepy, frustrated, anxious and worried.Reports pain killers don’t work, in agony all the time except when asleep. Has regular disagreements with his wife about what she perceives as his over use of pain killers. Withdraws to bedroom a lot and sleeps. Is irritable with family. Reports that his wife complains he is too sleepy and lethargic.Peter worries won’t ever get better, worries a lot about finances in relation to family and if family can survive on their income. Frustrated with the benefit system no help available.

BDI = 27 HADS: Anxiety = 18 Depression = 17 (severe range)Trauma screening = borderline Peter described no previous psychological difficulties and described his usual approach to life as ‘live life to the full’.

Psychologist allowed Peter to talk about the events and put into a narrative with as much detail and accuracy as possible during assessment.Established Peter’s primary concern’s regarding his current psychological responses and coping and from this developed a goal list.Education was provided regarding likely/normal reactions to these types of events and prolonged physical disability and pain. Education regarding chronic pain was provided and liaison undertaken to get seen by a chronic pain specialist.

Peter was also asked to observe the patterns in his mood using a weekly diary of his activity, his pain levels and his emotional responses which could be cross referenced so Peter could look for patterns – improvements or deteriorations in any of these areas and discover the precipitating factors to the changes.Problem solving approaches could then be applied – relaxation skills were learned, pacing skills, activity scheduling, avoidance of unhelpful activites. 

Peter was also asked to compile a list of pleasurable activities previously engaged with on his own and with his family so he could adapt or reengage with these. Peter was also asked to identify the tasks/roles that he saw himself being responsible for at home in order to understand how the accident and injury had interfered in his sense of himself his role his identity. Discussion about whether these were ‘all or nothing’, whether he could alter the emphasis he placed on certain aspects of himself.

Experiments were planned to re introduce paced return to some of the activities identified and further monitoring of mood and pain levels.Peter’s thoughts and beliefs were identified at times when he noted improvements or deteriorations in his mood/distress and when he noted motivational difficulties. Noticing and handling these thoughts and beliefs were practiced. Work continued in these areas for a number of months as Peter’s mood improved and engagement in his rehabilitation programme improved his physical functioning and coping with pain.