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Kiff Curve

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The Wiff Curve'
The 'Kiff Curve': An integrative model for
thinking about the provision of clinical
psychology
Joe Kiff
This paper describes an integrative model that I
have used for many years to understand what clinical psychologists do in adult mental health.
unpublished in the
academic literature, the integrative
model I describe in this article is not
new: I provided an early copy of this paper to
Mowbray as part of my submission to the
MAS review (Mowbray, 1989). Many of my
colleagues and supervisees have found it a
useful framework for thinking about clinical
issues. It developed out of my work in adult
mental health but colleagues from other
specialties have also found it helpful. In the
paper I hope to highlight some historical
trends that I believe have taken place over
the past couple of decades, the result of which
has meant that, for many of us, the bulk of
our work now lies with people with complex,
moderate to severe problems that pose difficult clinical challenges for all practitioners.
THOUGH PREVIOUSLY
The Model
In 1986, after I had been practising in adult
mental health for five years, I sat down to try
to clarify what I knew. I had originally
trained on the (then) behaviourally oriented
Birmingham course and subsequently completed the certificate in psychodynamic therapy at the Tavistock clinic. I had also been a
supervisor for the Lichfield counselling service for three years. By then I had personally
seen a broad spectrum of approximately 250
people and felt that I had developed a satisfactory grasp of behavioural, counselling and
psychotherapy techniques. The question at
the forefront of my mind was: what approach
seemed relevant to which kind of client?
46
Now, with over 17,500 hours of direct clinical
work and 3000 hours as a supervisor, I feel
the model I came up with provides a useful
framework for thinking about clinical issues
and for helpfully thinking about this question.
The model, which colleagues christened
the 'Riff curve', is represented in Figure 1.
On the y axis I wanted to get away from the
notion that the main therapeutic approaches
are mutually exclusive. I feel that I, and many
of my colleagues, work in three main modes:
• Prescriptive. With some people I primarily
give advice about practical courses of
action. Such people are often referred
with a specific problem and the active
ingredient of therapy has been to help
them make cognitive and behavioural
changes to resolve the presenting
problem. CBT and psycho-educational
models of working largely inform this
work.
• Supportive. Other people present with
problems that seem to reflect current
conflicts in their lives. They are
depressed and anxious because of social
and relationship conundrums that they
cannot resolve. In these situations the
active ingredient in the therapy appears
to involve providing a safe environment
from which people can clarify their
options and values and come to necessary
decisions to improve their lives. This
encompasses various humanistic models
(primarily Rogerian counselling).
III Exploratory. Other people are referred
with problems that appear to reflect
long-term patterns based on their early
life experiences. Current difficulties may
not be resolved at the supportive or
prescriptive level, and the active
Clinical Psychology Forum 204— December 2009
ingredient in the therapy involves
exploring the learning history and the
links between this and the person's
presenting problems. Primarily this
involves psychodynamic models.
I also attempted to place each client along a
continuum of 'mental health' (x axis). For
the majority of people seen, early life experiences mirror social and relationship functioning and the combination of these factors
relates to both the severity and complexity of
their problems. Taking account of these factors I found I could place people on a
notional Mental Heath Index. At one end
were people who seemed well integrated,
who were able to relate to me as a therapist
in a trusting and straightforward way. Generally speaking they appeared to come from
relatively stable family backgrounds, to have
rewarding social lives, usually living in a stable
relationship with someone who provided
some support, and were consulting with spe-
cific difficulties. At the other end were people
who seemed to have tremendous difficulties
relating to me, because they were psychotic,
extremely withdrawn or very emotionally
labile. Generally, they had experienced very
disturbed early lives, had disturbed (or nonexistent) current relationships and had a
whole plethora of problems, many of which
were severe, many of which had long histories. Placing people between these points I
started to see what approach seemed to be
effective for different clients. In making
sense of this picture I identified six loose
groupings that seemed to run into each
other although each seemed to warrant different interventions.
Group 1: Short-term directive therapy
This has worked well with well-integrated
people with specific problems. Such people
are often trusting and once a course of
action is explained to them they are able to
DEPTH OF
INTERVENTION
Prescriptive
Supportive
Exploratory
Good
MENTAL HEALTH INDEX
Poor
Figure 1: The Kiff curve
Clinical Psychology Forum 204 — December 2009
47
TJoe Kiff
cooperate and generally benefit quickly
from a symptomatic approach. At assessment
there seems to be little justification for looking more deeply into their current relationships or further exploring their early life. An
example of such a person might be a young
man involved in a road crash who has spent
six months recovering in hospital. Left with
residual anxiety about driving and a loss of
social confidence, having been out of circulation for so long, but with supportive
friends and family, he benefited from 6 sessions of anxiety management and social tasksetting, spread over 12 weeks at once a
fortnight intervals.
Group 2: Short-term supportive therapy
For people in this group counselling support
is the main intervention. For example, a
woman who nursed her ageing mother for
two years presented as depressed shortly
after her mother's death. With no evidence
that the relationship between mother and
daughter was particularly troubled, grief
counselling was appropriate. There was no
justification for exploring her early life and it
would be insensitive to treat the depression
as an isolated symptom. What was required
was to provide the space in which grief could
be explored, 'symptoms' understood, and
plans formulated for the future, on the basis
of her own values. In this case the woman felt
she had learnt a great deal about nursing
elderly people and wanted a job in a care
home. This helped resolve her existential
crisis, gave her satisfaction and purpose and
a basis on which to build a fresh life. We met
for eight sessions spread over five months,
meeting at fortnightly intervals.
Group 3: Short-term exploratory therapy
As clients come from more disturbed backgrounds they are less able to resolve their
current emotional difficulties without addressing the historical antecedents of these problems. For example, a woman who was having
difficulties in her second marriage, because
she could not trust her husband not to abandon her, in my opinion needed to examine
the idea that this was the issue behind her
first divorce, and appeared to be related to
48
The Wiff Curve'
the fact that her father left home unexpectedly when she was a child. In addition, it was
beneficial and important to address this
dynamic in the transference with her (male)
therapist, whom she had difficulty trusting.
Assuming a reasonably integrated client, a
short-term exploratory therapy (see Holmes,
1994), perhaps following Malan's model (see
Malan, 1979) seemed appropriate, and this
person benefited from 12 sessions of fortnightly psychotherapy spread over six months.
Group 4: Long-term exploratory therapy
With more damaged clients, longer-term
exploratory therapy might be indicated. For
example, if the client has been the victim of
physical violence when young and had a history of involvement with a sequence of men
who are violent to her, then one might anticipate that therapy might be more difficult
and time consuming. One sees the benefits
of longer-term work because the therapeutic
issues are more complex, the problems are
more pervasive and resistant to change, and
the technical challenge of maintaining the
therapeutic relationship is more taxing (but
ultimately rewarding for the client). The
woman described above eventually benefited
from meeting me 25 times spread over 18
months (initially weekly, then on a fortnightly basis, with two follow-up meetings at
three-monthly intervals).
Group 5: Long-term supportive therapy
For some clients the pain of working
through the past is too much to bear, at least
in the confines of NHS practice where the
pressure of referrals and waiting lists rarely
permits more than once a week therapy. For
this group longer-term, episodic, supportive
therapy is indicated to allow these people to
re-establish the status quo in their current
lives and to come to terms with the persuasiveness of their ingrained difficulties. For
example, one client told of an extremely difficult childhood with his prostitute mother.
Having six siblings, all by different fathers, it
seemed the only reason he was not more disturbed was because his aunt had taken him
away and provided a stable home when he
was seven. When he came to therapy, with
Clinical Psychology Forum 204— December 2009
crippling social anxiety, his aunt was dying. I
did not feel he was integrated enough to
withstand an exploratory approach, but he
related to me enough to benefit from a supportive relationship that took him through
the crisis. People in this group do not generally find a 'cure' for their condition, but can
be helped to manage their difficulties and
find less damaging ways of coping with their
problems. They are often re-referred at
other times of crisis in their lives. I have
come to see the value of offering intermittent time-limited treatment contracts to such
clients to provide support at particularly difficult times. The man described above met
me for three episodes of care, where I provided a containing, counselling relationship,
over a five year period, receiving eight then
two then five sessions each time he got in
contact. He did not wait on the waiting list
and sessions were offered as 'whenever necessary to contain crises'.
Group 6: Long-term prescriptive therapy
There are clients whose capacity to relate is
so impaired that they cannot easily profit
from a supportive or exploratory relationship alone, and their self-care difficulties
require the concrete structure of directive
approaches. The very socially isolated son of
a mother diagnosed as schizophrenic exemplifies this group. For much of our contact
he hardly seemed to engage meaningfully at
all and we seemed to inhabit different
worlds. It was only when we embarked on a
programme of basic social skills training
that he seemed to make significant progress.
People with ingrained and severe problems
in relating to others and few supportive relationships that they find meaningful seem to
benefit more from a fixed number of sessions while supported by other members of a
team. Our 16 sessions were spread out over
18 months, with an initial weekly focus to
establish the model then monthly and subsequently six-weekly monitoring meetings focusing on a specific aspects of his difficulties.
Some strengths of the model
•
The model underlines the importance
of psychologists equipping themselves
Clinical Psychology Forum 204 — December 2009
with a broad range of skills and
perspectives to be able to mix and
match their theoretical and practical
skills to the needs of the person. This
has implications for clinical training and
the need to develop the capacity of
learners to thoughtfully apply different
approaches.
• It helps us clarify the limitations of
therapy with group 5 and 6 people.
Coming out of a training that uses a
mastery model, newly qualified
psychologists spend years trying to find a
realistic level of therapeutic hope.
Avoiding interminable therapy with
these clients is key to maintaining
throughput and an important focus in
terms of minimising waiting lists. Many
psychologists struggle to apply the
evidence base on What Works for Whom
(e.g. Roth and Fonagy, 2004) and seem
to intuitively relate to the Kiff Curve in a
way that has greater impact on the
interventions they provide.
• For trainees faced with having to make
sense of a number of approaches and
therapy models the framework helps
them see how different models might be
related and effective in different
circumstances.
• When supervising trainees I endeavour
to ensure that they mostly start with
group 1 and 2 work, in order for them
to gain confidence. Then, should the
complexity of the work emerge with a
particular client, or there be opportunities
for trainees to see people from other
categories, I look to help them develop
their thinking from this base.
• The model integrates a number of
theories into a coherent whole and
illustrates integrationist working that I
think reflects the way in which many of
us work on a day-to-day basis.
III The model helps us understand the
compatible roles of different
professional groups within community
mental health teams. Nurse Behaviour
Therapists (and now Low Intensity IAPT
workers) might have the skills and be
the most appropriate people to do
49
Joe Kiff
•
•
•
mainly group 1 work; Counsellors and
High Intensity IAPT workers group 2;
Clinical Psychologists group 3 and 4;
Social Workers and CPNs group 5 and 6.
The model underlines the position that
the bread and butter work for psychologists
in these contexts is with the moderate
severity, moderate complexity patients
whose problems reflect their social
contexts and certain patterns from their
past, and whom frequently challenge
members of other professions who can
struggle to understand the underlying
basis of their difficulties.
The model illustrates level three
working (Mowbray, 1989) and managers
have found this useful in conceptualising
how psychologists contribute
therapeutically across the whole spectrum
of care, clarifying our central role in
assessment, allocation, supervision and
consultation.
The model is a useful framework from
which to consider the workload of an
individual, service or department; to
develop ideas for training; and to
consider skills mix and experience levels
regarding recruitment.
Conclusions
Following a plethora of changes in the NHS
two important trends have emerged. Many
people with more straightforward problems
and histories are no longer being referred
into psychology departments or CMHTs but
are instead being seen in primary care (e.g.
by IAPT workers). From the pool of difficult
cases remaining, many of the most complex
of these are allocated to clinical psychologists, perhaps as CMHT staff do not feel they
have the training or skills to help them
effectively. Such referrals are consistently
challenging and there is a feeling amongst
many experienced colleagues and newly
qualified psychologists that our clinical
training does not equip us for this work, particularly if it has been too limited in terms of
training in a particular model. Formulating
people's presenting problems and developing therapy plans can be quite a challenge,
as can managing feelings in the sessions and
maintaining an ability to think clearly in the
face of the confusing and contradictory
impacts associated with therapy in this client
group. Clinical trainers and CPD managers
will need to address these issues as they help
us prepare for this new emphasis in our
work.
Acknowledgment
Thanks to Guy Holmes for his endless
encouragement and for reading and commenting on various drafts
Affiliations
Joe Kiff: Dudley & Walsall Mental Health
Partnership NHS Trust
Address
Dr Joe Kiff, c/o Psychology Dept, Cross
Street Health Centre, Cross Street, Dudley
DY1 1RN; [email protected]
References
Holmes, J. (1994). Brief dynamic psychotherapy.
Advances in Psychiatric Treatment, 1, 9-15.
Malan, D. (1979). Individual psychotherapy and the science
of psychodynamics. Oxford: Butterworth.
Mowbray, D. (1989). Review of clinical psychology services. Cheltenham: 1\4AS. .
Roth, A. & Fonagy, P. (2004). What works for whom?
London: Guilford Press.
Visit the Division's website
www.bps.org.uk/dcp
50
Clinical Psychology Forum 204— December 2009
DCP Update
Obituary: Catherine Caulfield 1969-2008
Catherine died suddenly and unexpectedly
in November 2008, leaving behind a close
and loving family and a wide circle of friends
and colleagues, all of whom mourn her
death.
I first met Catherine when she joined
Lewisham & Guy's Trust psychology services
in 1997. I was immediately impressed by her
intelligence, her humour and commitment
to her work with children and families. She
was an incredibly warm and friendly person,
whom everyone liked. I was always pleased to
meet up with her, or to hear from her.
Cath was brought up in Whitley Bay in
North East England and studied psychology
at Leicester University. She trained in clinical
psychology at the Institute of Psychiatry,
graduating in 1997. Before her training as a
clinical psychologist, she was employed as a
research assistant with older adults at the
Maudsley Hospital. But after training, Cath
specialised in work with young people with
complex difficulties, doing so with great skill,
commitment and humanity. She worked in
four different teams and services within the
South London & Maudsley NHS Trust and
Guys & St Thomas's Hospitals before moving
to work at Great Ormond Street Hospital in
2008 to join their paediatric psychology team.
Cath specialised in paediatric neuropsychology and completed a postgraduate
diploma in clinical neuropsychology at IoP
in 2000. With other remarkable psychologists at the Newcomen Centre, she combined
her technical knowledge of brain and behaviour with a careful attention to, and respect
for, the wider needs of the child and the
family as a whole. She worked with children
with neurodevelopmental disorders at the
Newcomen Centre at Guy's Hospital in
1997, the brain and behaviour team at the
Maudsley Hospital until 2000, and from 2000
to 2003, the OCD team in the Children's
department with Isobel Heyman and psycholClinical Psychology Forum 204 — December 2009
ogy colleagues. She then moved back to Guy's
Hospital in 2003, to set up a psychology
service within the cleft palate service for
South Thames region. By this time she was
taking a lead clinical role in the team, conducting research and developing new services at a local level and nationally for
children with cleft palate and their families.
In 2008 she took up a senior psychology post
in immunology and ENT at Great Ormond
Street Hospital where, despite being there
only a short time before her death, she was
very highly regarded.
Right from the start of her career, her
senior psychology colleagues recognised her
abilities. A former research supervisor
described Cath as balanced, grounded, constructive, and 'emotionally intelligent'. Her
clinical child supervisor described her as
showing early signs as a trainee of becoming
the outstanding clinician she became, always
prepared to support others, and always prepared to go the extra mile with young people
that were difficult to engage. She was a
highly valued team colleague, described as
caring, supportive and 'lovely' to work with,
and generous with her time. She trained and
nurtured junior psychologists too. The
course tutor at IoP remembers her as an
excellent and popular supervisor and
teacher, and that all the trainees left their
placement with Cath singing her praises. He
recalls that mid-placement reviews always
ended with their having a laugh together.
And that smiling, sociable aspect of
Catherine is part of our memories of her as a
psychologist. One of her managers described
her as having a wonderful creative ability to
engage with children and make therapy fun.
Children whom she saw really enjoyed her
sessions. She was immensely likeable, with a
great sense of humour. She was always
friendly, and responsive to people around
her. From the start of her career she made
51
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