Presentation delivered by Dr Jason Chan, Highly Specialised Clinical Psychologist at the Acute COPD Early Response Service (ACERs) at the Homerton Hospital, at the Pan London Airways Network Winter Meeting 2015

1. Pan-London Respiratory Network (PLAN)
2nd November 2015
Psychological Barriers to engaging
Respiratory patients
Dr Jason Chan, Acute COPD Early Response Service
(ACERS)
Homerton University Hospital NHS Foundation Trust
DISCLAIMER: The views and opinions expressed in this presentation are those of the authors and do not
necessarily represent the views and policy of PLAN(Pan London Airways Network).

2. Setting the scene - Barriers for
whom?
• For patient: Psychological problems cause
barriers that hinder the patient’s journey of
adjustment to their progressive illness and
losses. They impede self-management, daily
functioning, and ability to receiving help.
• For clinicians: Psychological problems cause
barrier for our work to assist patients in
achieving their treatment and rehab goals.

3. Adjustment is a journey rife with
barriers & obstacles
A BILLNESS
TREATMENT &
REHAB GOALS
PSYCHOLOGICAL, SOCIAL &
ENVIRONMENTAL BARRIERS
RECOGNITION, UNDERSTANDING,
ENGAGEMENT SKILLS

4. Key enquiries in 30 minutes
1. What are the appearances of psychological
barriers in COPD patients?
2. Recognising the presence of psychological
barriers in clinical work
3. Engagement through a different kind of
conversation
4. Substantiating your hunch: Mood screen and
bedside assessment

5. 1. Psychological barriers in COPD: The
Obvious and the Ambiguous

6. The obvious
• Panic attacks due to COPD symptoms and the
overlapping of anxiety and breathless
symptoms
• Anticipatory anxiety: Fear of fear, fear of
COPD symptoms (e.g. breathlessness, cough,
reduced mobility, fatigue)
• Social anxiety, humiliation, embarrassment,
due to COPD symptoms and treatment
• Fear of side-effects of medications

7. The obvious (2)
• Overwhelming nature of anxiety produces
reactive coping strategies:
• Over- and inappropriate use of medications
(steroid, inhalers, nebulisers, antibiotics)
• Frequent and inappropriate use of emergency
services
• Avoidance of useful activities leading to general
loss of functions (e.g. Agoraphobia, refusing
exercises)
• Continue to smoke, use of alcohol and other
substance despite medical advice to the contrary

8. The less obvious
• Depression: Low mood, tearfulness, irritability,
report of helplessness, hopelessness and
suicidality
• Lack of motivation, energy and withdrawal
• Preoccupation with negative thoughts, worries
and rumination
• Stuckness with grievance, denial, guilt or shame
• Disrupted sleep and appetite
• Poor concentration, forgetfulness

9. The ambiguous
• Signs or subjective reports of Cognitive Impairments
without gross level of functional impairments:
• E.g. Attentional deficits, executive problems such as
poor planning, information processing, and problem-
solving, disorganised or overly concrete thinking, lack
of carry-over.
• Fundamental problems with using a helpful
relationship (e.g. boundary pushing, sporadic
attendance, unable to seek help or overly dependent)
• Poor emotional regulation
• Learning difficulties
• Other co-morbid mental health problems: PTSD,
psychotic features.

10. The ambiguous (2)
• Ambiguous psychological barriers are seldom
reported and mostly presents in behaviours and
the nature of relationship between the patient
and the clinician (or the health team).
• Sporadic contact with team (e.g. contact only in
crisis, verbal commitment but lack actual
engagement, DNAs)
• Inconsistency in narrative between different
clinicians
• Rigid decline of services or Over-reliance on team
for emotional support and unclear boundary

11. 2. Clarifying the Ambiguity:
Identifying subtle psychological
barriers in COPD patients

12. Psychological problems vs.
psychological barriers
• Psychological problems do not necessarily
cause barriers for patients to engage in
treatment
• Less about diagnosing mental health problems
than make astute clinical observations
• Identifying barriers help inform right clinical
decisions and treatment planning

13. Tuning into our unusual feelings: The
first line approach to screening
• How does the patient make you feel?
• Our own internal responses to a patient often
provides valuable information about what they
bring into the consulting room.
• For example, not every patient make us feel:
Hopeless, stuck, irritated or optimistic
• Key practice for psychologists to interpret their
unusual clinical experience of a patient to inform
assessment of the patient’s unmet needs.

14. Tuning into our unusual feelings (2)
• Do you…
• Dread seeing the patient and why? (
• Often go over-time in appointments?
• Really worried about them when they DNA?
• Notice that you seek-reassurance and talk to your
colleagues a lot about the patient?
• Worry about the patient over the weekend?
• Feel stuck but very guilty discharging the patient?

15. 3. Engagement: Having a different
kind of conversation

16. Engaging patients to address
Psychological barriers
• “Yes answers” often suggest the presence of
subtle psychological barriers to treatment
• Hard to address topics
• Expressing these issues can make patient feel
extremely vulnerable
• Experiences of being understood, safe and ability
to trust one’s clinicians are key to successful
engagement
• Therefore, exploration requires a different kind of
conversation

17. Empathic communication (see hand-out)
• Active Listening
- It sounds like you’ve been through a very tough time
- I can see that you are [angry]/ Am I right in thinking that you are feeling
[deeply scared/ sad/ helpless]?
- It must be very frustrating/ so it is a real problem for you/ no wonder you
are so angry/ it must be so frightening / I could hear that it bothers you a
lot.
• Asking relevant questions
- Can you tell me more? / what does it mean to you when your doctor said
you shouldn’t use the nebuliser at home?/ what’s so bad for you about
going to an exercise group?
• Summarising
- You are telling me that you feel blamed for using the rescue packs and it
makes you feel anxious about calling us?/ if I’ve understood correctly, you
can’t think about your own problems when you feel overwhelmed by
worries about your wife.

18. Empathic communication (2)
• Key points to note:
• Empathic communication is not an one-off technique
• A process of cycling through active listening, further
questioning and summarising to patient’s increasing
openness and an ever deepening level of
understanding
• Tentative, gentle voice, open-posture, same eye-level,
put aside medical notes, nodding
• Notice our compelling urges to – and avoid – offering
quick solution or reassurance (e.g. why don’t you…)
• Avoid making pre-mature conclusion (e.g. it is all in the
mind)

19. 4. Substantiating your hunch:
Standardised tool and bedside
screening

20. Standardised screening tool
• Hospital Anxiety and Depression Scales (HADS)
• 14- item self-report questionnaire (7 items on
each depression and anxiety symptoms)
• Severity rated on scale from 0-3 for each item
• Clinical cut-off 8/21 for both depression and
anxiety
• Can support patients in completing it
• It is a screening tool and results are NOT
diagnostic
• Further assessment is always required.

21. The Bedside 5-question screening
• How hopeful are you feeling about your
future?
• How often do you feel low in the morning,
even when you are not otherwise stressed?
• How often do you feel scared and worried?
• How often are you just angry?
• How often do you feel ashamed, guilty, or
have letting yourself or other people down?

22. The silent problems
• Remember there are often patients who you
think are in psychological distress but don’t
respond to direct questions or score highly on
screening tool
• The patient may be too frightened, not be
motivated, or not have enough insight about
their problems to seek help
• Resilience, age-group, social support, culture,
personality all play a part

23. 5. Integrated working & Getting help
• Psychological problems (e.g. depression and
anxiety) and barriers are very common in
respiratory illnesses but not inevitable
• Identification and clarification can lead to joint-
decision on treatment planning (e.g. addressing
issues and put treatment back on track or
understanding patients are not ready and facilitate
discharge and onward referrals)
• Referral to or consultation with in-service specialist
psychologists
• Discussion with GP or local Primary Care Psychology
(or IAPT Service)