Since specialising as a mental health pharmacist in 2003, my career has taken an unusual, but rewarding path. In addition to my role as a consultant clinical psychotherapist, I am a co-investigator for a Health Foundation-funded research programme and course lead for the postgraduate certificate in cognitive behavioural studies at the University of Oxford.
Source: Courtesy of Dan White
09:00 — start
My morning starts with my psychotherapist’s hat on. I have recently been appointed as one of the specialist cognitive behavioural therapists at Oxford Health NHS Foundation Trust to be part of a new national clinic, the Oxford Health Specialist Psychological Intervention Centre. I attend a clinical meeting where new referrals and ongoing treatment cases are discussed and allocated to appropriate therapists.
The clinic accepts referrals for people with treatment-refractory anxiety, obsessive compulsive disorder (OCD), a history of trauma and related conditions. The clinic director is professor Paul Salkovskis, a world-renowned cognitive behavioural therapist and leader in the treatment of OCD.
Following this meeting, I have a clinical supervision session with another member of the team. This provides an opportunity to reflect on and review practice; discuss individual cases in depth and change or modify practice; and identify training and continuing development needs. This is mandatory for all cognitive behavioural therapists accredited by the British Association of Cognitive and Behavioural Psychotherapies, of which I am a member.
Clinical supervision is usually undertaken as a one-to-one exercise, at least monthly, and is often supplemented with supervising a group session.
Today, there is a group session, for which I have been asked to give a short presentation to cognitive behavioural therapists on medicines used in anxiety treatment.
Exploring underlying beliefs and emotional states can facilitate re-evaluation of unhelpful behaviours and thoughts, leading to more functional actions
The talk briefly discusses National Institute for Health and Care Excellence guidelines and recommendations, but largely centres around how cognitive behavioural therapists can discuss medicines constructively with patients when they are brought up during therapy sessions — this is my specialism and the area I am researching for my PhD at the University of Oxford.
Cognitive behavioural therapy (CBT) posits the idea that it is not an event itself that determines people’s actions, but rather their thoughts, emotional states and urges. Exploring underlying beliefs and emotional states can facilitate re-evaluation of unhelpful behaviours and thoughts, leading to more functional actions and improved emotional states.
The therapists I am presenting to are highly skilled psychologists and psychotherapists and, thus, do not need to learn about therapeutic relationships or how to elicit a shared understanding of beliefs and experiences. However, perhaps because of the often polarised perception in which psychoactive medicines and talking therapies can be wrongly viewed, they can find it difficult to see how best to use their skills to help patients optimise their medicines.
I am not teaching them how to make pharmacological decisions, rather to use their everyday skills to formulate a behaviour — the act of taking or not taking a medicine that empowers the patient and facilitates better decisions.
Following supervision, I travel to Reading University to deliver a very similar presentation to pharmacy undergraduates. Despite addressing an entirely different healthcare group, the premise is the same — skills from CBT can be helpful in identifying and empathising with people who are having difficulty adhering to medicines and optimising drug therapy.
Learning points include how the importance of beliefs, motivations and behaviour models fit within Horne and Weinman’s ‘Necessity concern framework’, which assesses the relationship between a patient’s beliefs about their medicines and their adherence. I also cover how these ideas might be integrated with the ‘Ideas concerns expectations’ tool of patient centred care and nearly all the exercises I do are the same as those I use in training my colleagues. I find it truly fascinating that this single subject can be taught to such a diverse audience — I have now taught these ideas to GPs, consultants, nurses, pharmacists, medicines management technicians, occupational therapists and speech and language therapists.
My lecture finishes with getting the attendees to construct a case example demonstrating shared understanding following non-adherence.
I use a case example where a patient (JB) is concerned about starting the antidepressant mirtazepine. When asked, JB reveals that the side effect he is most worried about is drowsiness. JB thinks that if he starts mirtazepine he will become too sleepy to interact with his friends, will spend even longer in bed, will not be able to concentrate at college and will have to give up driving. Ultimately, he thinks that this will make his low mood even worse. JB is understandably worried, anxious and somewhat sceptical about taking his antidepressant, as evidenced in that he has picked up his prescription, but has not taken it yet.
Here, JB is showing several thoughts/beliefs, which in turn create negative emotions (anxiety, worry, pessimism) and determine his behaviour. In this instance: he is avoiding taking his newly prescribed medicine.
This is a shared understanding. When we reach this point with patients, we are able to empathise with them and tell them that, “given these thoughts and feelings, it is no wonder that it has been difficult to adhere to medicine” (we are not condoning this behaviour, just understanding why it has occurred), at which point we are able to offer a number of interventions.
After a late lunch, I lead another clinical supervision group — this time for the clinical pharmacy team working for forensic services in Oxford. This team cares for patients with the most severe and enduring mental health illnesses within our trust. Many of the patients have a history of violence and their stories and history can be disturbing and saddening. Hearing these stories and working with them to try to promote recovery can be extremely challenging.
The pharmacy team has asked if they can have a supervision session that focuses on coping with distressing stories, developing awareness of the personal impact of these stories and maintaining optimism, compassion and hope for this patient group.
A colleague volunteers a recent situation in which she encountered a newly admitted patient with a tragic background. It affected the pharmacist deeply and when she asked the more experienced pharmacy team members how they coped, they found that they were unable to articulate a particularly helpful answer.
In CBT, we identify several thinking ‘habits’, ‘styles’ or ‘biases’ that can lead us to make negative predictions and jump to negative conclusions. Deploying these thinking habits is universal and not usually problematic, until we start to assume that our thoughts are facts, as opposed to ideas or opinions that we hold. In discussing the pharmacist’s thoughts about this case, we were able to ascertain that the pharmacist was having specific negative thoughts around the magnitude of the patient’s problems, and whether she could possibly make things better for this patient. These thoughts had led the pharmacist to feel hopeless and left her questioning her clinical service.
Upon learning about thinking habits and through our group discussion, the pharmacist was able to acknowledge that she was making negative predictions, jumping to conclusions and discounting the positives in the situation. She also recognised that she was treating these negative thoughts as facts.
This exercise immediately took some power away from these thoughts, which then allowed us to focus on information that had been discounted. For example, the pharmacist identified that, while the patient’s recovery had been slow, there was undoubtedly progress. The pharmacist also realised that she had stopped noticing that the rest of the clinical team had not given up on this lady and were actively trying to support her in promoting recovery. The pharmacist then remembered that this patient had a loving and supportive family — the patient’s mother and sister visited often.
Finally, we discussed situations where different people had overcome overwhelming adversity to eventually lead meaningful lives.
These exercises completely shifted the pharmacist’s view of this case. The tragic facts of the patient’s history were unchanged, but the pharmacist had realised there was still hope. Although she has no way of predicting the future, she can do her best to give patients a real opportunity for meaningful recovery.
We finished the session by consolidating our learning and created several bullet points that would form a guideline to help new and visiting staff, such as trainee technicians and preregistration pharmacists.
17:00 — finish
Before going home for the day, I reflect on how, before walking into my last supervision group, I didn’t know what to expect. As usual, I had my own doubts about whether I could help. I am now accustomed to these thoughts and feelings. Although they are still unpleasant, I have an abundance of my own success stories on how utilising CBT techniques within a pharmacy setting, such as during patient consultations and clinical supervision, appears to be of huge benefit to my practise, my patients, my colleagues and myself.
Box: Are you interested in a similar role?
- My role as a consultant clinical psychotherapist is banded as NHS Agenda for Change band 8c. The banding for my specialist mental health pharmacist role is band 8a;
- Combining cognitive behavioural therapy techniques (CBT) and clinical pharmacy is a novel and emerging concept and as such, formal qualifications and training are not available. For those interested, a good place to start is with introductory mental health courses;
- ‘Psychiatry 1’ training run by the College of Mental Health Pharmacy provides an intense introduction to psychopharmacology and clinical pharmacy services for those working in mental health. I am involved in facilitating a two-hour workshop presenting the above ideas during weekends;
- The Oxford Cognitive Therapy Centre has an abundance of courses for those largely working in mental health, who are interested in learning more about CBT;
- The UK Society for Behavioural Medicine is an organisation dedicated to behaviour change in healthcare settings, including improving adherence (not CBT-specific);
- The British Association for Behavioural and Cognitive Psychotherapies is a multidisciplinary interest group for people involved in the practice and theory of behavioural and cognitive psychotherapy.