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How to talk about variations in sex development is a major theme for impacted individuals and families. This is the topic of Chapter 12. The author summarizes the research literature with caretakers and with adults about the difficulties of disclosure. Considerable criticism has been levied at health professionals for failing to role model affirming communication. For sure there are gaps in health professionals’ talk, but the biggest contributor to the difficulties is to do with the widespread misunderstanding about the biological variations. Psychological care providers are not there to put a cheerful gloss over clients’ negative expressions. However, they can be part of the favorable social condition in which a wider range of meanings about bodily differences are negotiated. In the practice vignette, the author highlights how tentative and uncertain the enabling process is, where a negative view of sex variations is still widely endorsed in the social context.
In a gendered world, doctors and caretakers took for granted that making atypical bodies more typical was a humane way out of a difficult situation for child and family. Had the professionals carried out proper research, they would have learned from their young patients that the approach was physically and psychologically risky. But research on the long-term effects was not carried out, certainly not from the patients’ perspective. There was also no comparison group made up of people growing up with unaltered genital variations. Research with adults is the topic of Chapter 4 of this book. Since the 1990s, a number of outcome studies with adults have identified many problems of childhood surgery, such as multiple operations, scarring, shrinkage, sensitivity loss, unusual genital appearance and sexual difficulties.
Chapter 8 begins by pointing out the current lack of collective clarity about the role of psychological care providers (PCPs) and suggests that researchers and practitioners make collective effort to develop the role of PCPs in sex development in future. Meanwhile it outlines the psychological consultation process that is generic and familiar to most PCPs. The author provides an initial assessment template and summarizes the popular psychotherapeutic interventions. The template is visible in several of the practice vignettes in the ensuing chapters of the book. The author ends the chapter by arguing that the tertiary environment is set up for diagnostic workup and treatment and unsuitable for the kind of ongoing psychosocial input that is needed by individuals and families living in their communities. The author makes a case for PCPs in DSD centers to collaborate with peer support workers to enable nonspecialist providers in the community to contribute to ongoing support for individuals and families.
Chapter 11 of the book reviews potential psychological contributions in the highly charged process of assigning legal gender to a newborn with genital variations. Although a number of psychological theories exist for understanding gender development, it is the brain gender framework that has been singularly privileged in intersex and DSD medicine. However, the decades of research cannot contribute to the certainty professionals and caretakers seek. Psychological care providers (PCPs) have other frameworks to draw from in order to work ethically and pragmatically with families. In the practice vignette, the author envisions how a highly skilled PCP in a high-functioning DSD team could work substantially to help caretakers to cope with uncertainty and minimize the need for psychosocially motivated medical interventions. In the vignette, the psychological care path is in position before medical investigations begin. It remains highly active long after the medical and legal processes are completed. Although the vignette is built around a child diagnosed with 17β-hydroxysteroid dehydrogenase-3 deficiency, the care principles are relevant to legal binary gender assignment for children born with a range of sex development variations.
Difficulties with communication about bodily differences are strongly linked to sexual experiences. In Chapter 13, the author critiques the dominant ways of talking about sexuality in the wider society. These oppressive ideas can give rise to insecurities, self-objectification and body shame for people in general. Adults who have been medically managed are particularly vulnerable to the effects of objectification and shame. The author outlines typical components of sex therapy programs. However, rather than fix sexual problems, which can perpetuate people’s sense of inadequacy, the author suggests that psychological care providers support clients to process any trauma and develop a more relaxed and appreciative relationship with the body. This work, which requires generic therapy knowledge and skills, can be integrated with a range of specific sex therapy techniques and resources to reimagine a sexual future that focuses on bodily pleasure rather than gender performance. Although the practice vignette is built around a female couple, one of whom has partial androgen insensitivity syndrome, the care principles have wide applications for people with variations more generally.
Inconsolable distress is neither a universal nor inevitable response to inability to have biological children. In Chapter 14, the author criticizes research with clinic samples that has produced a problem-saturated account of childlessness that obscures a wide range of alternative responses. The author examines the influence of pronatalist ideology on people who are impacted by infertility including many people with sex variations. Away from the treatment context, psychological input can guide individuals, couples and groups to explore personal meaning of nonparenthood. It can facilitate service users to grieve for what is not possible, challenge feelings of deviance and shame, reengage with a range of life goals and, perhaps most important of all, recast adult identities. Through the practice vignette built around a heterosexual couple, one of whom has a late diagnosis of Klinefelter syndrome, the author teases out the difficulties of working psychologically in a treatment context, where complex existential issues and relational dynamics are compressed into the frame of pressurized treatment decisions.
Chapter 9 tackles the theme of choosing “normalizing” interventions, which applies to children and adults with variations. It explores the limits of choice regarding invasive and irrevocable “normalizing” interventions in the field of sex development. It considers the role of emotion in decision-making and the complexities of obtaining informed consent. In the practice vignette, demand for surgery by a young person (with CAH) is a foregone conclusion – a familiar scenario in DSD services and one that places the psychological care provider (PCP) in an ambiguous position. The service user also has clear psychosocial care needs. She brings a unique suite of intersecting social circumstances that place demand on the PCP to be fluid and responsive to the dynamic and challenging referral context. The PCP in the vignette does not have the answers, but it is hoped that the story opens up conversations on the theme.
Psychological care is endorsed in DSD medicine. Psychosocial research has been on the increase. But these positive moves have not given psychological practice the kind of collective focus that is enjoyed by the biomedical disciplines. However, psychological care providers have a wide variety of thinking tools and practice techniques to draw on, if to work in an ad hoc way at times. These tools and techniques do not change, but some are more useful and relevant than others for this service context. In Chapter 7, the author discusses the strengths and weaknesses of key theoretical frameworks in healthcare psychology. A major weakness of the individualistic models is their lack of capacity to address structural inequalities in psychological wellness and distress. The author introduces aspects of the Power Threat Meaning Framework and describes how to draw from its theoretical richness to think systemically about what sex variations pose to individuals and families in the social context and how they are responded to. The Framework provides the theoretical backbone for some of the practice vignettes in the final section of the book (Chapters 9–14).
In Chapter 10, the author suggests immense possibilities for psychological care providers (PCPs) to contribute to compassionate care following the birth of a child with variations (and in the antenatal period). Psychosocial research and first-person accounts inform us of caretakers’ brokenness, which is often responded to by “normalizing” the child. Here, the author suggests that PCPs work with caretakers in a grief-informed way. Grief is a language that everyone understands and compels services to privilege psychological safety as a first care principle. The practice vignette is built around an expectant mother in difficult circumstances with an unborn child with TS. However, the concept of grief is also relevant for older children and adolescents who are newly diagnosed. Indeed processing loss is integral to adjustment, whereby taken-for-granted ideas of selfhood give way to new identities.
Biological variations in sex development, also known as intersex, are greatly misunderstood by the wider public. This unique book discusses psychological practice in healthcare for people and families impacted by a range of 'intersex' variations. It highlights the dilemmas facing individuals and their loved ones in the social context and discusses the physical and psychological complexities of irrevocable medical interventions to approximate social norms for bodily appearance and function. It exposes the contradictions in medical management and suggests valuable theoretical and practice tools for psychosocial care providers to navigate them. Uniquely featuring theory and research informed practice vignettes, the book explores interpersonal work on the most salient psychosocial themes, ranging from grief work with impacted caretakers to sex therapy with impacted adults. An indispensable resource for working ethically, pragmatically and creatively for a variety of healthcare specialists and those affected by variations in sex development and their families and communities.
It is essential to conduct randomised controlled trials of psychological interventions on acute psychiatric wards to build a robust evidence base for clinical practice.
This paper aims to share strategies from three different in-patient trials that successfully recruited and retained participants, to disseminate good practice for the conduct of future trials in this challenging and complex clinical setting.
We present strategies from three in-patient trials of psychological interventions: TULIPS (Talk, Understand, Listen for Inpatient Settings), amBITION (Brief Talking Therapies on Wards) and INSITE (Inpatient Suicide Intervention and Therapy Evaluation). All studies recruited participants from acute in-patient wards, initiated therapy within the in-patient setting and followed up on participants post-discharge.
We summarise our recommendations for good practice in the form of ten top tips for success, based on our collective experience of conducting trials on psychiatric wards. Key themes relate to the importance of relationships between the research team and clinical staff; good stakeholder involvement and getting early buy-in from the team; and adapting to the particular demands of the clinical setting.
Sharing good practice recommendations can help reduce research waste arising from poor recruitment and/or retention in future in-patient clinical trials.
The chapter describes how the clinical psychologist can work in rural and remote settings. The specific rewards and challenges are outlined. The chapter reviews the effectiveness of therapy at a distance and developments in the delivery of clinical psychology services. Consideration is given to the relevant legislation and regulations, and provides a practical guide to providing therapy at a distance. These steps involve a consideration of privacy and security, risk management, telehealth, and adapting therapeutic skills to the digital and distance context. The chapter concludes with the unique elements of mental health services in rural communities and the impact on professional boundaries of life in small communities.
The science-informed approach to clinical practice is founded upon ongoing quality improvement and involves key skills that allow clinical psychologists to confidently provide services in a competitive health care market. Thus, programme evaluation is a core clinical psychology competency but needs to be provided via a co-design framework. The chapter outlines how co-designed programme evaluation addresses patients’ needs in five steps: (i) asking the right questions, (ii) developing an evaluation plan, (iii) collecting and analysing data to produce usable findings, (iv) translating the findings into recommendations for action, and (v) advocating and promoting change. The chapter illustrates how empirically-based programme evaluation supports accountable clinical practice, both at the level of the individual patient and at the aggregate level of the service provider or agency.
After assessing a client a treatment plan is required. The chapter outlines the practical steps in proceeding from a case formulation to a treatment plan. Since many techniques are modified for application in many different clinical problems and psychological disorders, we will concentrate on providing a description of particular procedures that are broadly applicable. The chapter provides practical illustrations of treatment planning with outlines of behaviour therapy, dialectical behaviour therapy, cognitive therapy, and interpersonal psychotherapy. It includes specific examples of clinical cases and explains how these approaches can be subsumed under a transdiagnostic framework of treatment planning. Consideration of transdiagnostic interventions involves targeting negative affect, intolerance of uncertainty, anxiety sensitivity, avoidance and safety behaviours, emotion regulation, and metacognitve therapy.
The chapter outlines low intensity psychological Interventions (LIPIs). These are treatments that have low usage of a specialist’s therapist time (e.g., 5–8 sessions), or uses the time in a manner that reaches a large number of people. Low intensity does not refer to the client’s experience. Even though the contact with the specialist is less, the client’s involvement in terms of time, effort and emotional investment can be intense. The chapter outlines in a practical manner stepped-care, how to offer choice to service users, and shared decision-making. Given that LIPIs can be challenging to master, the chapter provides an illustrative example of adapting case formulation and treatment planning to this mode of delivery.
The chapter outlines an evidence-based approach for clinical psychologists to select and provide group treatments. The process begins with selecting the appropriate treatment programme and then selecting the appropriate patients for the group. The chapter will identify principles for selection and assessment as well as how the use of interpersonal interaction as a therapeutic tool in the here-and-now context of a group can be an inherent advantage of group interventions. In addition, it outlines practical steps for implementation of a group that includes pre-group orientation, enlisting patients as informed allies, providing guidelines about how best to participate, clarifying the format and duration, setting ground rules, anticipating problems and instilling optimism among members. The chapter concludes with a consideration of how monitoring of process and outcomes can enhance outcomes.
Clinical psychology is at an exciting point in time. We describe the current state of clinical psychology, framing it in terms of a trajectory from the foundation of the scientist-practitioner model to present developments. The chapter outlines how the how core competencies of clinical psychology practice are framed by the question, “How would a scientist-practitioner think and act?” We present a model of science-informed practice of clinical psychology and illustrate how this model allows individual practitioners to provide value for money in a competitive health care market indelibly shaped by the forces of accountability and cost containment. The model illustrates how the client is viewed through a lens of evidence-based literature and clinical experience, and how a clinical psychologist collaborates with a client in assessment, case formulation, treatment planning, process-informed treatment delivery, treatment measurement and monitoring, to permit evaluation and accountability. It concludes with a consideration of the perspectives of the key stakeholders, namely the client, the therapist and the broader society, and how these perspectives shape interest in the monitoring of effectiveness, efficacy and understanding of the mechanisms and processes responsible for mental health problems.
Case formulation links the client and his or her problems with the treatment. It captures both the strengths and the weaknesses in a complete summary of the client. The chapter introduces case formulation by first describing a behavioural case formulation and how a functional analysis can be conducted. The illustration of a behavioural formulation is then developed into a model that goes beyond identifying the antecedents and consequences of behaviours, and includes reference to the potential of mediation by thoughts and beliefs. Thus, a broader cognitive-behavioural model of case formulation distinguishes steps: (i) presenting problems, (ii) predisposing factors, (iii) precipitating variables, (iv) perpetuating cognitions and consequences, (v) provisional conceptualization, (vi) prescribed interventions and (vii) potential problems and client strengths. The chapter then provides two clinical examples of case formulation, beginning with a cognitive-behavioural case formulation then an example from the perspective of interpersonal psychotherapy. The chapter concludes with a discussion of transdiagnostic approaches to assessment and case formulation.
The evidence-based practice of clinical psychology may begin with a review of efficacy studies, but it cannot end there. It needs to translate these data to the patient who presents for treatment. The chapter begins with a discussion of the principles whereby a clinical psychologist can seek to match evidence-based treatments to a client’s clinical presentation. The chapter additionally reviews future developments in personalized medicine and methods that have the potential to improve the matching of treatments to presenting problems. The chapter also considers how session-to-session progress can be monitored to identify when a patient’s progress deviates (either positively or negatively) from an expected course. The concept of clinical significance is described, and practical illustrations are provided of how this can be used to monitor progress and ways of responding to clients who are on and off track are outlined. The discussion of why Routine Outcomes Monitoring systems work is demonstrated by illustrating implementation in routine clinical conversations.