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The role of the clinical psychologist
Old age psychiatric services
The role of the clinical psychologist
diagnosis, the delivery of psychological treatment, teaching and training, research, audit and clinical management.
Charles Twining
In helping older people we are often trying to distinguish between the effects of normal ageing and illness or impairment (Table 1). This is especially challenging for early or mild disease and very important when treatment is aimed at slowing or, better still, preventing progressive deterioration. Norm-based psychological tests are now widely available, covering age groups from child hood to old age, although normative data on those aged over 90 years are still comparatively rare (Table 2). There is growing interest in the use of computer-based tests, which are increas ingly accessible for older patients. Experience in the adminis tration of tests to older people is essential so that appropriate allowance can be made for sensory deficits, fatigue and so on, both in the choice of test and the interpretation of the results.
Assessment
Abstract The clinical psychologist brings to the practice of mental healthcare of older people knowledge-based psychological skills in relation to people, ageing and disease. Key areas for the use of these skills include the disturbances of cognition, including memory, mood and behaviour. Psychological tests are increasingly available with appropriate norms into advanced age and can help distinguish early cognitive decline from age-related changes. They are particularly useful in atypical cases and where premorbid features may influence presentation. They are also helpful in assessing mental capacity, and the clinical psychologist has core skills relevant to this. As well as assessment of mood, psychological approaches are also important in the treatment of mood disorders, using individual and systemic approaches. The evidence base indicates that psychological treatment should be combined with pharmacological treatment. Psychoeducation programmes are also effective in reducing carer strain. The clinical psychologist can contribute to the training and supervision of other staff in the practice of psychological treatments. This includes the management of challenging behaviour using psychological approaches. The key outcomes in old age psychiatry include psychological variables such as quality of life. The clinical psychologist can make a major contribution to audit and service evaluation, and there are several areas where assistant psychologists can give additional support. The clinical psychologist has skills relevant to the support, facilitation and management of clinical teams.
Cognition High-quality neuropsychological tests offer detailed analysis of cognitive function either free from, or with known correction for, such variables as premorbid intelligence, education and previous occupation. The effects of premorbid IQ often significantly con taminate simple screening tests (e.g. the ubiquitous Mini-Mental State Examination) such that, for example, a perfect score in someone of above-average intelligence can mask very important underlying deficits. The clinical psychologist can therefore carry out more detailed assessment with selected patients and also can advise on the choice and quality control of routine measures to be used by other assessors. Capacity and consent Structured normative analysis can make a significant contribu tion to advising on issues of mental capacity. Legislation in Scot land has already resulted in a growing contribution by clinical psychologists to this area of work; it is expected that the cor responding legislation in England and Wales will similarly allow the law there to catch up with developments in best practice. Under the draft Mental Health Bill, the role of the responsible medical officer (RMO) is replaced by that of clinical supervisor. This position is not restricted to consultant psychiatrists but is open to other suitably qualified professionals, such as consul tant clinical psychologists. The Mental Capacity Bill draft code of practice recognizes that clinical psychologists can provide expert evaluation of mental capacity.
Keywords assessment; challenging behaviour; clinical psychology; cognition; mental capacity; mood; staff support
Psychology is the scientific study of behaviour; clinical psycho logy is the application of this to healthcare. The clinical psychol ogist therefore brings to the practice of mental healthcare of older people knowledge-based skills in relation to people, ageing and disease. These are core skills for the multidisciplinary team. Key areas for the use of these skills include the disturbances of cog nition (including memory, mood and behaviour) that are at the heart of mental illness in later life. The clinical psychologist has a unique contribution to make to the process of assessment and
Psychological changes in normal ageing • Reduced information-processing capacity, including: • decreased cognitive speed • reduced ability to divide attention/multi-task • Mild memory changes, e.g. name retrieval • Slight increase in emotionality • Increased reliance on familiar problem-solving strategies
Charles Twining OBE MA MSc PhD AFBPsS is a Specialist in Health and Social Care Policy for older people. He read natural sciences at Cambridge University and qualified in clinical psychology from Oxford University. He worked in the NHS for more than 30 years, specializing in the care of older people. His interests include early dementia and issues relating to mental capacity.
PSYCHIATRY 7:2
Table 1
73
© 2007 Elsevier Ltd. All rights reserved.
Old age psychiatric services
Examples of neuropsychological tests with norms for older people Test
Features
Repeatable Battery for the Assessment of Neuropsychological Status Wechsler Memory Scale – Third Edition – Abbreviated (WMS-III-Abbreviated) Kendrick Assessment Scales for Cognitive Ageing The Hayling and Brixton tests Wechsler Abbreviated Scale of Intelligence (WASI)
12 subtests Age range: 20–90 years
Key influences in ageing and wellbeing Thoughts
Social context
Personal history
Four subtests Age range: 16–89 years Four subtests Age range: 40–92 years Two tests of executive function Age range: 18–80 years Four subtests Age range: 6–89 years
Feelings
Behaviour
Physical factors Table 2
Mood Mood disorders are the commonest mental health problems in later life. Careful assessment is required to determine whether such disorders really are of clinical significance, and to recognize what could be improved. Appropriate tests with norms and indi vidual mood ratings can help with diagnosis and the assessment of treatment outcome.
Figure 1
Carer support Evidence from controlled trials shows the benefits of structured psy cho-educational programmes for carers, including carers of stroke patients and those with dementia. Such programmes improve carer wellbeing, reduce length of hospital stay and reduce rates of admission to long-term care. On such indices the benefits are at least as great as those of the drugs currently licensed for dementia. These programmes should be part of routine clinical practice.
Treatment Clinical psychologists’ core training includes the theory and practice of a range of evidence-based psychological therapies. The best use of the clinical psychologist, whose skills will include aspects of therapy supervision, will be in the support of others in their therapeutic work, as well as being the ther apist of choice for more complex cases. This applies not only to individual therapy, such as cognitive–behavioural therapy (CBT), but to the design and evaluation of individual beha viour programmes and work with families or other systemic approaches.
Teaching/training and supervision/consultation Psychological skills Psychological skills are not just important for psychologists: staff who deal with older people need appropriate interpersonal skills. These are especially important in the delivery of mental health services, as the patient–staff relationship is a major determinant of patient outcome. Clinical psychologists’ training includes the teaching/training of psychological skills and can therefore be used in the development of other staff. The practice of trained counselling requires ongoing supervision, and the clinical psy chologist will often be the appropriate person to provide this.
Individual treatment Treatment guidelines for conditions such as anxiety and depres sion highlight the merits of combining psychological and phar macological treatments, especially for moderate-to-severe cases. It is now widely accepted that psychological approaches are just as applicable to older as to younger people. Indeed, the increased impact of drug side effects, drug interactions and co-morbidity sometimes makes psychological therapy the treatment of choice. Patients and their families increasingly expect such treatments to be available.
Therapy supervision and consultation Therapies such as CBT are sometimes described as ‘manual ized’, which means that someone who is suitably trained can apply them. But, however careful the selection of cases, more complex problems than those covered by the manual do some times emerge. There needs to be broader and deeper psychologi cal expertise available to deal appropriately with such problems; access to more expert consultation is therefore an important part of making this work and ensuring quality control.
Family interventions Family members and other informal carers, who will often have a lifelong relationship with the patient, provide most older people’s care. Psychological treatment therefore needs to be set in a family and wider social context (Figure 1), where systemic approaches are highly relevant.
PSYCHIATRY 7:2
Student training Many teams will have students from various disciplines attached for varying periods of their training. Some, such as trainee 74
© 2007 Elsevier Ltd. All rights reserved.
Old age psychiatric services
sychiatrists, will be expected to gain some experience of psy p chological therapy under appropriate supervision, which the clinical psychologist can provide.
recruitment of qualified clinical psychologists is still sometimes a problem. Where there is a qualified clinical psychologist in post there is often a good deal of scope for adding input from assistant psychologists. Such posts are in great demand from psychology graduates who wish to gain relevant experience to strengthen their position in applying for clinical training. Supervised by a clinical psychologist, they can make significant contributions to areas such as routine evaluations in memory clinics, support work with relatives and many other areas.
Care staff Many staff, especially front-line staff in residential and nursingcare homes, need to understand psychological issues. Dementia is a factor in most admissions to residential and nursing homes and staff training can have a major impact on residents’ wellbeing. This is most obviously seen in the development of Dementia Care Mapping. This is a detailed observation tool for use in formal dementia care settings; it is designed to examine quality of life from the perspective of the person with dementia and is used as part of improving care standards. Challenging behaviour – understanding the effects of cogni tive impairment and emotional distress can radically alter staff attitudes and behaviour. Behavioural analysis and interventions that have been clearly agreed, consistently implemented and carefully monitored are important tools in managing difficult behaviour. Staff need training and psychological advice to use these to best effect. This is especially important given the risks associated with the use of atypical antipsychotics in dementia.
Staff support and management Even more than in most other areas of healthcare, mental health services rely on staff much more than on equipment. Staff need maintenance and support, as is illustrated by the increasing aware ness of work-related stress as a major cause of sickness and absence. The clinical psychologist has skills relevant to the support, facilita tion and management of clinical teams, and there are examples of clinical psychologists who have taken on the role of clinical director of a service, including in the area of old age mental health. It would be wasteful not to use their skills to help with team management and support, especially in the constantly changing environment of healthcare. Team morale is a key determinant of clinician outcome and psychological interventions at both organizational and indi vidual level can be effective in improving staff wellbeing. ◆
Audit, research and evaluation Clinical psychology has been described as being based on the ‘scientist–practitioner’ model. Research design and analysis are core skills for both undergraduate psychology and postgraduate clinical training. Putting the research and evaluation skills of the clinical psychologist to work in the team is not only sensible, it makes the post more attractive. The use of these skills is increas ingly important with the move from input and process measure ment of performance to outcome-based performance management. Any ‘business case’ for improving services will carry much more weight if it can show how implementation affects patient out come. The key outcomes in old age psychiatry include psycho logical variables such as quality of life and carer mental health. The clinical psychologist can make a major contribution to this aspect of service evaluation. Good evaluation and relevant clini cal research will enhance recruitment across the professions.
Further reading Martin C. The role of the clinical psychologist in the assessment, diagnosis and management of depression in older people. In: Curran S, Watts JP, Lynch S, eds. Practical management of depression in older people. London: Arnold, 2001. (A useful summary of the clinical psychologist’s contribution). Stuart-Hamilton I. The psychology of ageing, 3rd edn. London: Jessica Kingsley, 2000. (A useful general introduction). Woods RT, ed. Handbook of the clinical psychology of ageing. Chichester: Wiley, 1996. (The standard British text). Woods RT, ed. Psychological problems of ageing: assessment, treatment and care. Chichester: Wiley, 1996.
Recruitment issues There has been a significant increase in the numbers of clini cal psychologists training in the UK over recent years, although
PSYCHIATRY 7:2
75
© 2007 Elsevier Ltd. All rights reserved.
The role of the clinical psychologist
diagnosis, the delivery of psychological treatment, teaching and training, research, audit and clinical management.
Charles Twining
In helping older people we are often trying to distinguish between the effects of normal ageing and illness or impairment (Table 1). This is especially challenging for early or mild disease and very important when treatment is aimed at slowing or, better still, preventing progressive deterioration. Norm-based psychological tests are now widely available, covering age groups from child hood to old age, although normative data on those aged over 90 years are still comparatively rare (Table 2). There is growing interest in the use of computer-based tests, which are increas ingly accessible for older patients. Experience in the adminis tration of tests to older people is essential so that appropriate allowance can be made for sensory deficits, fatigue and so on, both in the choice of test and the interpretation of the results.
Assessment
Abstract The clinical psychologist brings to the practice of mental healthcare of older people knowledge-based psychological skills in relation to people, ageing and disease. Key areas for the use of these skills include the disturbances of cognition, including memory, mood and behaviour. Psychological tests are increasingly available with appropriate norms into advanced age and can help distinguish early cognitive decline from age-related changes. They are particularly useful in atypical cases and where premorbid features may influence presentation. They are also helpful in assessing mental capacity, and the clinical psychologist has core skills relevant to this. As well as assessment of mood, psychological approaches are also important in the treatment of mood disorders, using individual and systemic approaches. The evidence base indicates that psychological treatment should be combined with pharmacological treatment. Psychoeducation programmes are also effective in reducing carer strain. The clinical psychologist can contribute to the training and supervision of other staff in the practice of psychological treatments. This includes the management of challenging behaviour using psychological approaches. The key outcomes in old age psychiatry include psychological variables such as quality of life. The clinical psychologist can make a major contribution to audit and service evaluation, and there are several areas where assistant psychologists can give additional support. The clinical psychologist has skills relevant to the support, facilitation and management of clinical teams.
Cognition High-quality neuropsychological tests offer detailed analysis of cognitive function either free from, or with known correction for, such variables as premorbid intelligence, education and previous occupation. The effects of premorbid IQ often significantly con taminate simple screening tests (e.g. the ubiquitous Mini-Mental State Examination) such that, for example, a perfect score in someone of above-average intelligence can mask very important underlying deficits. The clinical psychologist can therefore carry out more detailed assessment with selected patients and also can advise on the choice and quality control of routine measures to be used by other assessors. Capacity and consent Structured normative analysis can make a significant contribu tion to advising on issues of mental capacity. Legislation in Scot land has already resulted in a growing contribution by clinical psychologists to this area of work; it is expected that the cor responding legislation in England and Wales will similarly allow the law there to catch up with developments in best practice. Under the draft Mental Health Bill, the role of the responsible medical officer (RMO) is replaced by that of clinical supervisor. This position is not restricted to consultant psychiatrists but is open to other suitably qualified professionals, such as consul tant clinical psychologists. The Mental Capacity Bill draft code of practice recognizes that clinical psychologists can provide expert evaluation of mental capacity.
Keywords assessment; challenging behaviour; clinical psychology; cognition; mental capacity; mood; staff support
Psychology is the scientific study of behaviour; clinical psycho logy is the application of this to healthcare. The clinical psychol ogist therefore brings to the practice of mental healthcare of older people knowledge-based skills in relation to people, ageing and disease. These are core skills for the multidisciplinary team. Key areas for the use of these skills include the disturbances of cog nition (including memory, mood and behaviour) that are at the heart of mental illness in later life. The clinical psychologist has a unique contribution to make to the process of assessment and
Psychological changes in normal ageing • Reduced information-processing capacity, including: • decreased cognitive speed • reduced ability to divide attention/multi-task • Mild memory changes, e.g. name retrieval • Slight increase in emotionality • Increased reliance on familiar problem-solving strategies
Charles Twining OBE MA MSc PhD AFBPsS is a Specialist in Health and Social Care Policy for older people. He read natural sciences at Cambridge University and qualified in clinical psychology from Oxford University. He worked in the NHS for more than 30 years, specializing in the care of older people. His interests include early dementia and issues relating to mental capacity.
PSYCHIATRY 7:2
Table 1
73
© 2007 Elsevier Ltd. All rights reserved.
Old age psychiatric services
Examples of neuropsychological tests with norms for older people Test
Features
Repeatable Battery for the Assessment of Neuropsychological Status Wechsler Memory Scale – Third Edition – Abbreviated (WMS-III-Abbreviated) Kendrick Assessment Scales for Cognitive Ageing The Hayling and Brixton tests Wechsler Abbreviated Scale of Intelligence (WASI)
12 subtests Age range: 20–90 years
Key influences in ageing and wellbeing Thoughts
Social context
Personal history
Four subtests Age range: 16–89 years Four subtests Age range: 40–92 years Two tests of executive function Age range: 18–80 years Four subtests Age range: 6–89 years
Feelings
Behaviour
Physical factors Table 2
Mood Mood disorders are the commonest mental health problems in later life. Careful assessment is required to determine whether such disorders really are of clinical significance, and to recognize what could be improved. Appropriate tests with norms and indi vidual mood ratings can help with diagnosis and the assessment of treatment outcome.
Figure 1
Carer support Evidence from controlled trials shows the benefits of structured psy cho-educational programmes for carers, including carers of stroke patients and those with dementia. Such programmes improve carer wellbeing, reduce length of hospital stay and reduce rates of admission to long-term care. On such indices the benefits are at least as great as those of the drugs currently licensed for dementia. These programmes should be part of routine clinical practice.
Treatment Clinical psychologists’ core training includes the theory and practice of a range of evidence-based psychological therapies. The best use of the clinical psychologist, whose skills will include aspects of therapy supervision, will be in the support of others in their therapeutic work, as well as being the ther apist of choice for more complex cases. This applies not only to individual therapy, such as cognitive–behavioural therapy (CBT), but to the design and evaluation of individual beha viour programmes and work with families or other systemic approaches.
Teaching/training and supervision/consultation Psychological skills Psychological skills are not just important for psychologists: staff who deal with older people need appropriate interpersonal skills. These are especially important in the delivery of mental health services, as the patient–staff relationship is a major determinant of patient outcome. Clinical psychologists’ training includes the teaching/training of psychological skills and can therefore be used in the development of other staff. The practice of trained counselling requires ongoing supervision, and the clinical psy chologist will often be the appropriate person to provide this.
Individual treatment Treatment guidelines for conditions such as anxiety and depres sion highlight the merits of combining psychological and phar macological treatments, especially for moderate-to-severe cases. It is now widely accepted that psychological approaches are just as applicable to older as to younger people. Indeed, the increased impact of drug side effects, drug interactions and co-morbidity sometimes makes psychological therapy the treatment of choice. Patients and their families increasingly expect such treatments to be available.
Therapy supervision and consultation Therapies such as CBT are sometimes described as ‘manual ized’, which means that someone who is suitably trained can apply them. But, however careful the selection of cases, more complex problems than those covered by the manual do some times emerge. There needs to be broader and deeper psychologi cal expertise available to deal appropriately with such problems; access to more expert consultation is therefore an important part of making this work and ensuring quality control.
Family interventions Family members and other informal carers, who will often have a lifelong relationship with the patient, provide most older people’s care. Psychological treatment therefore needs to be set in a family and wider social context (Figure 1), where systemic approaches are highly relevant.
PSYCHIATRY 7:2
Student training Many teams will have students from various disciplines attached for varying periods of their training. Some, such as trainee 74
© 2007 Elsevier Ltd. All rights reserved.
Old age psychiatric services
sychiatrists, will be expected to gain some experience of psy p chological therapy under appropriate supervision, which the clinical psychologist can provide.
recruitment of qualified clinical psychologists is still sometimes a problem. Where there is a qualified clinical psychologist in post there is often a good deal of scope for adding input from assistant psychologists. Such posts are in great demand from psychology graduates who wish to gain relevant experience to strengthen their position in applying for clinical training. Supervised by a clinical psychologist, they can make significant contributions to areas such as routine evaluations in memory clinics, support work with relatives and many other areas.
Care staff Many staff, especially front-line staff in residential and nursingcare homes, need to understand psychological issues. Dementia is a factor in most admissions to residential and nursing homes and staff training can have a major impact on residents’ wellbeing. This is most obviously seen in the development of Dementia Care Mapping. This is a detailed observation tool for use in formal dementia care settings; it is designed to examine quality of life from the perspective of the person with dementia and is used as part of improving care standards. Challenging behaviour – understanding the effects of cogni tive impairment and emotional distress can radically alter staff attitudes and behaviour. Behavioural analysis and interventions that have been clearly agreed, consistently implemented and carefully monitored are important tools in managing difficult behaviour. Staff need training and psychological advice to use these to best effect. This is especially important given the risks associated with the use of atypical antipsychotics in dementia.
Staff support and management Even more than in most other areas of healthcare, mental health services rely on staff much more than on equipment. Staff need maintenance and support, as is illustrated by the increasing aware ness of work-related stress as a major cause of sickness and absence. The clinical psychologist has skills relevant to the support, facilita tion and management of clinical teams, and there are examples of clinical psychologists who have taken on the role of clinical director of a service, including in the area of old age mental health. It would be wasteful not to use their skills to help with team management and support, especially in the constantly changing environment of healthcare. Team morale is a key determinant of clinician outcome and psychological interventions at both organizational and indi vidual level can be effective in improving staff wellbeing. ◆
Audit, research and evaluation Clinical psychology has been described as being based on the ‘scientist–practitioner’ model. Research design and analysis are core skills for both undergraduate psychology and postgraduate clinical training. Putting the research and evaluation skills of the clinical psychologist to work in the team is not only sensible, it makes the post more attractive. The use of these skills is increas ingly important with the move from input and process measure ment of performance to outcome-based performance management. Any ‘business case’ for improving services will carry much more weight if it can show how implementation affects patient out come. The key outcomes in old age psychiatry include psycho logical variables such as quality of life and carer mental health. The clinical psychologist can make a major contribution to this aspect of service evaluation. Good evaluation and relevant clini cal research will enhance recruitment across the professions.
Further reading Martin C. The role of the clinical psychologist in the assessment, diagnosis and management of depression in older people. In: Curran S, Watts JP, Lynch S, eds. Practical management of depression in older people. London: Arnold, 2001. (A useful summary of the clinical psychologist’s contribution). Stuart-Hamilton I. The psychology of ageing, 3rd edn. London: Jessica Kingsley, 2000. (A useful general introduction). Woods RT, ed. Handbook of the clinical psychology of ageing. Chichester: Wiley, 1996. (The standard British text). Woods RT, ed. Psychological problems of ageing: assessment, treatment and care. Chichester: Wiley, 1996.
Recruitment issues There has been a significant increase in the numbers of clini cal psychologists training in the UK over recent years, although
PSYCHIATRY 7:2
75
© 2007 Elsevier Ltd. All rights reserved.