Access to and adequacy of psychological services for adult patients in UK hospices: a national, cross-sectional survey.

BACKGROUND: Providing psychological support to people living with terminal illness is a fundamental part of hospice care. Recent research on delivery of psychological services in hospices in the United Kingdom (UK) on a national level, including inequalities or variation in practice, is limited. A nationwide survey will highlight any differences in provision and in doing so help focus future research and inform best practice both within the UK, and internationally. The specific objectives of this survey are to (1) chart the types of psychological support available to adult patients in hospices in the UK in line with the National Institute for Health and Care Excellence model; (2) explore how services are organised; and (3) gather service perspectives on adequacy of care, and facilitators and barriers to appropriate practice. METHODS: A cross-sectional online survey emailed to adult hospices in the UK in November-December 2019. One staff member involved in the delivery and/or organisation of psychological support was invited to participate per hospice. Of 193 invited hospices, 116 took part. RESULTS: Sixteen percent rated their hospice psychological service as wholly adequate. The majority reported that services can access specialist professionals, but many relied on external referrals. Barriers to best practice included funding and staff capacity; facilitators included clear referral structures, audit and appropriate needs and outcome assessments. CONCLUSIONS: Access to psychological professionals has improved since the last survey 15 years ago, but the majority of responders felt their overall service was not wholly adequate. Basic emotional support is largely felt to be sufficient, but our results indicate a need for improvements in access to more specialist care. Partnerships with external mental health services may be key. Our findings highlight core facilitators and barriers to providing good psychological care at the end of life that should be considered by services both within the UK and on an international level.

Compassion focused therapy: a systematic review of its effectiveness and acceptability in clinical populations.

Introduction: Compassion focused therapy (CFT) is an increasingly popular therapeutic modality. Its holistic and integrative approach to universal human suffering means that it is well placed as a transdiagnostic therapy. Research into its effectiveness and acceptability has increased over the previous 10 years as the therapy has evolved, and to help consider its status as an evidence-based therapy research concerning its treatment outcomes needs evaluating.Areas covered: This paper reviews research investigating the effectiveness of CFT in clinical populations.Expert opinion: CFT shows promise for a range of mental health problems, especially when delivered in a group format over at least 12 hours. This is important for funding bodies and commissioning groups to consider as they allocate healthcare resources in light of current evidence-based practice. CFT is demonstrably well accepted by clients and clinicians and there is now a clear need for an updated, universally deployed, standard manual to direct future research. This will be critical in enabling widespread implementation and further adoption into mainstream clinical practice, will address the lack of standardization in the current research, and pave the way for further randomized control trials aimed at reducing existing methodological limitations.

"I'm Still Fighting for the Two of Us": How Partners of UK Veterans Construct Their Experience of Living with Combat-Related Trauma.

There has been little qualitative research into the experiences of UK partners of veterans with PTSD. This study therefore aimed to explore how partners constructed their experiences of living with the condition. Fifteen female partners of male UK veterans were recruited and interviewed. Using a social constructionist thematic analysis, five themes were constructed: the women's need to subdue own emotional and behavioral responses; dilemmas about whether the veteran was unwell or 'bad'; attempts at negotiating multiple roles; challenging the narrative of veterans as heroes; and the relational struggle with the transition to nonmilitary life. This study highlighted the importance of considering the veteran as existing within a relational and cultural context, and the need to include partners in therapeutic interventions.

Compassion focused therapy for people with dementia: A feasibility study.

OBJECTIVES: There is a lack of evidence-based psychological therapies for dementia and psychological distress. The study aimed to develop a compassion focused therapy intervention for people with dementia with depression and/or anxiety, and to assess its feasibility, acceptability, and utility. METHODS: A mixed methods multiple case series (n = 7) was used to assess the intervention's feasibility and changes in self-compassion, mood, anxiety, and quality of life. Outcome measures were administered at pre-intervention, midpoint, and post-intervention. Data were analysed using reliable change and clinically significant change. Thematic analysis on post-therapy interviews and session rating forms was used to assess acceptability and perceived change from the intervention. RESULTS: Over the course of the intervention, improvements in mood, anxiety, and self-compassion were seen, and three of six participants moved out of the clinical depression range. Six participants were able to engage in soothing rhythm breathing, and five in discussion of self-criticism and developing self-compassion. Several participants and their carers described increased self-compassion in response to cognitive decline. CONCLUSIONS: Compassion focused therapy can be adapted to be delivered to people with dementia and low mood, anxiety, or other distress. The intervention may improve self-compassion, mood, and anxiety. A larger pilot trial with a comparator group and follow-up is needed to evaluate the intervention's effectiveness for people with dementia.

A longitudinal investigation of repressive coping and ageing.

OBJECTIVES: Two studies investigated the possibility that repressive coping is more prevalent in older adults and that this represents a developmental progression rather than a cohort effect. Study 1 examined repressive coping and mental health cross-sectionally in young and old adults. Study 2 examined whether there was a developmental progression of repressive coping prevalence rates in a longitudinal sample of older adults. METHOD: Study 1 compared younger adults (mean age 27.6 years) with older adults (mean age 74.2 years) on inventories of mental health and well-being and examined the prevalence of repressive coping in both samples. Study 2 re-tested a sample of older adults previously reported following an interval of 7 years. RESULTS AND CONCLUSION: Study 1 - in line with previous research older adults demonstrated greater psychological well-being and had a higher prevalence of repressive coping than younger adults (at 30% vs. 12% respectively). Study 2 - the data indicated that the prevalence of repressive coping rose from 41% at the first time of testing (2002) to 56.4% at the second testing interval (2009). These results suggest that repressive coping may increase across the lifespan in certain individuals and continue to increase throughout older adulthood. Furthermore, this increase in repressive coping with age appears to result in better well-being in those older adults who become repressive copers.

Distress in working on dementia wards - A threat to compassionate care: A grounded theory study.

OBJECTIVES: Nurses and health care workers are under increasing scrutiny from the general public and other professionals over their capacity for compassion. For example, in the UK, recruitment of nurses includes assessment of compassion through 'Values Based Recruitment'. However, compassionate care can be hindered when working in very challenging and pressurised environments. The study aimed to explore the experiences of managing work pressures in front-line NHS staff caring for older adults with dementia. One aspect of the analysis was to explore the factors that facilitate or hinder self-compassion and mindfulness, since these ways of responding to extreme pressure are likely to facilitate compassion towards others. METHOD: Ten front-line staff (a mixture of nurses and Health Care Assistants) from three inpatient dementia wards took part in qualitative interviews which were then analysed using constructivist grounded theory methods. RESULTS: A theoretical framework was generated which highlighted the role of structural and interpersonal types of work pressure on individual responses and ways of managing pressure. A range of helpful and unhelpful strategies were employed and although many participants appreciated the importance of taking time to process and reflect on difficult emotions and experiences during work, there were significant structural and personal barriers to practicing mindfulness and self-compassion more fully. A sense of professionalism along with various organisational factors meant that much processing of difficult emotions had to take place largely out of work hours. CONCLUSIONS: Recruiting staff with high levels of compassion and training compassion to existing staff are not likely to significantly improve compassionate care alone in the context of extremely challenging work environments. Rather, organisational changes need to be made to model and reward self-compassion; staff training should focus on self-compassion and mindfulness, without which compassion to others is hindered. Strong professional values which may instil in care staff a belief in not displaying emotions at work should be considered carefully by professional bodies in order to provide guidance from pre-qualification onwards about how to balance professional conduct with appropriate expression of emotion in response to extreme situations.

Social rank and symptom change in eating disorders: a 6-month longitudinal study.

BACKGROUND: Following previous cross-sectional research adopting an evolutionary approach to social rank and eating disorders, the present study explored the predictive value of social rank for changes in eating disorder symptoms in a 6-month longitudinal study. METHODS: Seventy-three women and men with a history of eating disorders were followed up over 6 months. A broad range of measures of social rank were used to determine whether social rank at baseline predicted residual changes in eating disorder symptoms. RESULTS: Low social rank (in terms of perceived external entrapment and submissive behaviour) predicted an increase in symptoms of anorexia but not symptoms of bulimia. The predictive value of low social rank was not mediated by changes in depressive symptoms. CONCLUSION: Perceived low rank predicts an increase in anorexic symptoms. However, further research is required to determine the precise nature of how social rank exerts its influence on the development of eating disorder symptoms. KEY PRACTITIONER MESSAGE: Self-perceived low social rank predicts an increase in anorexic symptoms but not bulimic symptoms. The effect of low social rank on changes in anorexic symptoms was not mediated by changes in depressive symptoms. Interventions for anorexia nervosa may need to incorporate techniques for increasing status and/or self-compassion.

Social defeat and PTSD symptoms following trauma.

OBJECTIVES: Research indicates that constructs relevant to social rank predict a diagnosis of post-traumatic stress disorder (PTSD), including mental defeat, alienation, and shame. However, no studies have yet explored a social rank view explicitly. DESIGN: This was a community-based study carried out online. Analyses were both cross-sectional and longitudinal over 6 months. METHODS: Participants were recruited online for a cross-sectional study (Study 1, n = 194) and a 6-month longitudinal study (Study 2, n = 81). Measures included self-report measures of PTSD symptoms (the Post-Traumatic Diagnostic Scale) and social rank (including measures of unfavourable social comparison, social defeat, and internal/external entrapment). RESULTS: Cross-sectional analysis showed that social defeat, but not other aspects of social rank, was independently predictive of a diagnosis of PTSD. Longitudinal analysis showed that greater social defeat at baseline predicted less improvement in PTSD symptoms, whereas greater reduction in social defeat over the 6-month follow-up predicted greater improvement in PTSD symptoms. CONCLUSIONS: In addition to the implications for understanding the role of social (rather than individual mental) defeat in the aetiology of PTSD, interventions could usefully incorporate methods that either increase social status or else minimize the impact of low status (e.g., through the use of compassion-focused approaches).

That's just life: older adult constructs of trauma.

OBJECTIVES: Researcher, clinical professional and lay understandings of the meaning of trauma may differ. An awareness of older people's perspectives on trauma may be important, given the potential for historical and cultural features to shape how the term is conceptualised among this group, thereby influencing related help-seeking behaviour. METHOD: Older people living in Essex, Cambridgeshire and Suffolk were interviewed about their perceptions of the term, as was a group of mental health professionals who work with the elderly. RESULTS: Many older people regarded significant adversity as just part of life, with collectively understood methods of avoidance or limited support-seeking pointing to emotional management through non-disclosure. This position seemed further informed by views that disclosure may be self-indulgent, which is in stark contrast to the historical and cultural background in which many older people were raised. The professionals also suggested that some older people may be unused to expressing their emotions. The concept of trauma seems to be relative, with stigma and shame appearing to influence the way that responses to adversity are managed by this age group. CONCLUSION: [corrected] We conclude that focused history taking by clinicians may be needed to help elicit symptoms of trauma among elderly patients, while at the same time services might engage in a compassionate dialogue to encourage those suffering in silence to seek help.

The emergence of posttraumatic distress in later life: a review.

We review the literature for evidence of posttraumatic stress disorder that emerges in older adulthood yet is related to earlier life events. Minimum standards necessary to establish the phenomenon are proposed and applied to existing group and case studies. Our findings suggest that the best evidence for this rests with a handful of group studies featuring male war veterans (n = 4) and a variety of case studies (n = 12) that have appeared over the last two decades. We summarize what is known regarding prevalence, symptoms, course, and triggers, and conclude that the phenomenon does exist but has rarely been investigated systematically. There are therefore no grounds at present for thinking of reemergent posttraumatic stress disorder as a unique subtype of the disorder among elderly people. We suggest that future research focuses in more detail on participants' history of posttraumatic difficulties and considers the phenomenon across groups other than male veterans.

The phenomenology of reactivated trauma memories in older adults: a preliminary study.

Empirical literature concerning reactivated memories of trauma among older adults is sparse. Twelve elderly participants with re-emergent, involuntary, memories of previous adversity were given a structured interview exploring phenomenological aspects of the experience. Intense and highly vivid sensory components of memory were common as was a sense of current threat. This was compared with data available from the adult literature on post-traumatic stress disorder (PTSD) and we conclude that the process of trauma memory reactivation after years of attenuation seems not to have affected involuntary intrusive representations of what happened. Recommendations to extend the current research are suggested.