10/02/2009

Complex Cases Complex Cases ServiceService

RochdaleRochdalePresents:‘NICE start, but is it time to NICE start, but is it time to

get nasty?’get nasty?’A synopsis of how we have implemented and audited

NICE Guidelines, and attempted to use them for the optimal benefit of our clients!

TheThe

First a case study, about Millie:

Millie has a diagnosis of BPD

and has been in and out of psychiatric

hospitals since the age of 14!

Millie’s parents were harsh and neglectful. From the outset they

were not interested in Millie. She was just their possession; not a person in her own right. When she was tiny, they left her crying in hunger and distress. They did not interact with her and would hit her if she protested too much about her discomfort. For Millie, this had 2 direct consequences:

(1). Millie learned that the world was hostile and unpredictable and that people are cruel and not to be trusted; this left her feeling continually anxious and fearful.

(2). The development of Millie’s brain was compromised, because poor attachment between an infant and its primary caregivers, leads to poor attachment between the brain’s emotion production centre and its emotion regulation and problem-solving centres. In practice, this meant that Millie experienced extreme and rapidly changing emotions, without being able to exercise control over them or problem-solve her way out of the crises that triggered the emotions.

By the time Millie went to school, she felt unlovable and struggled to have normal relationships. Her rapidly changing andextreme moods made her unpopular with

everyone, as she would either lash out at other children or cut herself off and refuse to play with them. She wanted to fit in, but had no idea how to make others like her. She ended up being bullied by her peers. The teachers were highly critical, accusing Millie of having temper-tantrums. Her parents continued to be cruel and abusive towards her and, by the time she reached her mid-teens, Millie had already tried to take her own life three times. Just being alive was so emotionally painful, she used alcohol, drugs, cutting and overdosing to try and block out the hurt.

Millie isn’t a real personBut she may just as

well beBecause she represents so many of the women & men I’ve worked with over the yearsNot only has she been neglected and rejected by her family, peers and teachers, Mental Health Services have continued to treat her in this manner…….

Who would

choose to have a life like Millie’s?

Yet historically, the attitude of mental health services has

been to blame people like

Millie for their own situation!

Millie, like so many others with

‘Personality Disorder’, has been a victim of:

Diagnosticism!

“The

y’re

not

real

ly il

l are

they

” “They’re just messing

about aren’t they”“It’s not like schizophrenia is it;

People can’t help having that!

“If there’s two people on the

ward saying they’re going to kill

themselves, who are you going

to go to, the person who’s really

ill, or the one who’s just p-----

g

about?”

“They should pull

themselves together and

stop wasting precious time

and resources”

Racism

Sexism

Ageism

‘Diagnosticism’

They’re about:

• injustice

• unfairness

• intolerance

• discrimination

• misuse of power

…and about excluding people

from their right to a fair share of

society’s resources!And until 6 years ago ‘Diagnosticism’ was used to

deny people with PD the treatment they needed and

deserved

But research during But research during the 1990’s and early the 1990’s and early

2000’s, sewed the seeds 2000’s, sewed the seeds for a change in attitude; for a change in attitude;

evidence began to evidence began to accumulate about the accumulate about the

biological, psychological biological, psychological and social causes of and social causes of

personality disorder and personality disorder and about its treatability. about its treatability. People with PD who People with PD who

wanted help, could no wanted help, could no longer be ignored!longer be ignored!

And came up And came up with some with some bright new bright new

ideasideas

Personality Disorder: No

longer a diagnosis of exclusion

2003

Let’s make

‘‘NICE’NICE’ People

Which, together Which, together with the NIMHE with the NIMHE

document, created document, created the impetus for the impetus for

NHS Trusts to set NHS Trusts to set up dedicated P D up dedicated P D

TeamsTeams

With a set of Guidelines for

BPD

To address the following key priorities To address the following key priorities

NICE NICE GuidelineGuidelines for BPDs for BPD

Assessment & treatment for

the most complex & high

risk clientsConsultation Consultation & advice to & advice to other teamsother teams

Help in the manageme

nt of individual

cases

Facilitate good communicatio

n & information

sharing

Networking with other agencies, including,

forensic, CAMHS, Social Care

Provision of longer-

term, evidence-

based therapies

Develop & provide training programmes

Oversee the implementation of

NICE guidance

Rochdale Rochdale Complex Complex

Cases ServiceCases Service Pennine Care NHS Foundation Trust

Fully operational since April 2008

2007 - Remit to develop a specialist PD Service (with limited resources):

‘Hub & Spoke’ Service Model

Specialist

‘Hub’COMPLEX CASES

Team

CMHT’s

Wards

Psychological Therapy Teams

O/P Psychiatry

Review & Recovery Assertive

Outreach Team

Social Care

Crisis Resolution /

HTT

Day Services

Substance Misuse

Services

The ‘Hub’ Team

• Clinical Lead / Consultant Clinical Psychologist

• Operational Manager / Senior M H Nurse

• Clinical Psychologist

• Psychology Assistant

• Skills Therapist / M H Nurse

• A&C

So what do So what do we do and we do and what have what have

we we achieved?achieved?

Client Group

Adults of working age, who are care co-ordinated & meet the following criteria:

• ENDURING mental health / personality-based problems

• SEVERE impact on everyday functioning (relationships, work/education, social & leisure, etc)

• COMPLEX presentation (e.g. history of neglect, trauma/abuse, attachment disruption, etc)

• High RISK to self and/or others (violence & aggression, self harm, suicidality, neglect, child protection issues, etc.)

Role of Hub TeamRole of Hub Team• Comprehensive Psychosocial Assessment

• Individual Complex Formulation

• Formulation Driven Management Plan

• Evidence Based Skills interventions

• Insight Based Therapies

• Supervision, teaching/training of ‘Spoke’ Teams

• Consultation/liaison

We recognise that most of our clients have experienced invalidation throughout their lives, even at the hands of mental health services

Therefore, we want them to know from the outset that we genuinely value and respect them

We try to send out this message in a number of different ways……..

The Importance of The Importance of ValidationValidation

Therapy rooms are made to feel welcoming and relaxing

We have placed maximum effort into developing high quality information leaflets taking advice from service

user representatives

The same applies to our Skills-Based Therapy handouts which

have been carefully thought through and made as accessible

and user-friendly as possible

We ensure that we explain all aspects of what’s on offer in a clear, unambiguous manner so our clients are empowered to make decisions about their own treatment

With their consent, we make sure that we track down and review all their available mental health, health and social care records

All of this information is combined into a biopsychosocial formulation, which draws on theoretical models to form the basis for appropriate evidence-based interventions

We take our time in getting to know our clients (typically assessment = 3 sessions)

                                                                    

           

Individual Genes Biology Neurochemistry Neuroanatomy

AttachmentSocial OpportunitiesEnvironment Socio-Economic Circumstances

Culture & Religion

Cognitive Style

PersonalPsychology Emotional Responsiveness Learned/Conditioned Behaviours

+

Our FORMULTIONS are all UNIQUE to the Our FORMULTIONS are all UNIQUE to the INDIVIDUAL CLIENTINDIVIDUAL CLIENT

We believe it is hugely important to tailor our

service to each individual client, and to work

collaboratively with them to try and make sense of their

journey through life, and how it has resulted in them being stuck in patterns of self-defeating thoughtsself-defeating thoughts

and behavioursbehaviours

That’s why, That’s why, everything we everything we

do is driven do is driven by the by the

formulation formulation and NOT a and NOT a diagnostic diagnostic

labellabel

Working within the Care Programme Approach (CPA), we aim to bring all other member’s of their care team on board,with a unified ‘Multi-Agency ‘Multi-Agency

Management Plan’Management Plan’ (a M-AMP), based on the formulation

This approach places the client’s needs at the heart of the intervention and is designed to promote consistency and safe containment from the care team

We monitor the implementation of the M-AMP via the CPA process as well as MDT meetings, consultation sessions and clinical supervision of the remainder of the care team

Therapeutic Therapeutic InterventionsInterventions

Skills Enhancement Programmes:Skills Enhancement Programmes:• Taught skills to replace unhelpful ‘coping’ strategies• Tailored to the needs of each individual client• To help them manage their distress in a safe manner• All founded on therapies with a strong evidence base

(e.g. DBT, CBT)

Insight-Based Therapies:Insight-Based Therapies:• Longer term evidence-based therapies to promote more

fundamental change (at a thinking and feeling level)• The aim is to increase self-awareness and empower the

individual to have real choice about how to live their lives in the future

Client and Staff Feedback Client and Staff Feedback QuestionnairesQuestionnaires

Have been administered to clients and MDT staff members with the following results:

Clients:Clients:

•Environment – 15/20Environment – 15/20

•Clinicians – 25/30Clinicians – 25/30

•Information – 12/15Information – 12/15

•Therapy Handouts – Therapy Handouts – 18/2018/20

•Other Comments:Other Comments: “Very helpful, but hard”

“Too much noise in the corridor” “A brew would help”

Staff:Staff:Information – 12/15Information – 12/15

Involvement 4/5Involvement 4/5

Formulation Feedback – 17/30Formulation Feedback – 17/30

M-AMPs – 17/20M-AMPs – 17/20

Consultation & Supervision – 9/10Consultation & Supervision – 9/10

Effectiveness of therapy – 8/10Effectiveness of therapy – 8/10

Other Comments: Other Comments: “Provides a safe, accountable framework for managing risk in the community”

“Needs more clinicians”

Training Training EventsEvents

By helping other professionals to understand the biological, psychological and social origins of personality and personality disorder, and by supporting them in their involvement with our joint clients, we aim to increase their interestinterest and enthusiasmenthusiasm for working with people with personality-related mental health difficulties

We want staff to feel greater confidenceconfidence and competencecompetence to work with clients with complex presentations

Above all, we aim to increase compassioncompassion and empathy empathy for our clients, so that they feel valued and listened to

Training Outcomes

0

10

20

30

40

50

60

70

80

90

Understanding20% - 74%

Competence14% - 42%

Interested 61% - 90%

Before

After

We are in for the long-We are in for the long-haul, interested in haul, interested in providing quality providing quality

services to our clients, services to our clients, but this high intensity but this high intensity

approach requires approach requires justification if we are justification if we are

to survive in the to survive in the current economic current economic

climate!climate!

So we are auditing level of service use before, during and after involvement with our team

M H admissions Contacts with Care Co-ordinator

In-patient days Visits to A & E

Planned psychiatry appointments

Number / type of medical admissions

Unplanned Psychiatry appointments

Police contacts

Number of contacts with CRHT

Incident reports

X.X. Timeline of Service Contact

0

10

20

30

40

50

60

70

80

01.05.05 01.11.05 01.05.06 01.11.06 01.05.07 01.11.07 01.05.08 01.11.08 01.05.09

Time (6 Monthly Intervals)

Fre

qu

en

cy o

f C

on

tact

Number of days admitted

Psychiatry contacts

Number of contacts with CRHT

Number of contacts with carecoordinator

Number of incident reports

Number of A & E contacts

Days medically admitted

Number of police contacts

1st

Assessm

en

t

Inte

rven

tio

n 1

(S

kills

-Based

)

Inte

rven

tio

n 2

(In

sig

ht

Th

era

py)

Y.Y. Timeline of Service Contact

0

5

10

15

20

25

01.01.05 01.07.05 01.01.06 01.07.06 01.01.07 01.07.07 01.01.08 01.07.08 01.01.09 01.07.09

Time (6 Monthly Intervals)

Fre

qu

en

cy o

f C

on

tact

Number of days admitted

Psychiatry Contacts

Number of contacts with CRHT

Number of Contacts with CareCoordinator

Number of incident reports

Number of A & E Contacts

Days medically admitted

Number of Police Contacts

1st

Assessm

en

t

Inte

rven

tio

n 1

(In

sig

ht

Th

era

py)

Inte

rven

tio

n 2

(S

kills

-Based

)

Z.Z. Timeline of Service Contact

0

5

10

15

20

25

30

35

40

45

50

01.03.06 01.09.06 01.03.07 01.09.07 01.03.08 01.09.08 01.03.09 01.09.09

Time (6 Monthly Intervals)

Fre

qu

ency

of

Co

nta

ct

Number of days admitted

Psychiatry contacts

Number of contacts withCRHT

Number of contacts withcare coordinator

Number of incident reports

Number of A & E contacts

Number of contacts withsupport worker

Police contacts

1st

Ass

essm

ent

Inte

rven

tio

n 1

(In

sig

ht

Clinical Outcomes Clinical Outcomes (Client **)

TARGET TARGET BEHAVIOURSBEHAVIOURS

To reduce:

•Staying in bed

•Drinking binges

•Brief, intense relationships

•Episodes of self-harm

•Social Isolation

•Angry, aggressive outbursts

0

2

4

6

8

10

02.03.08

05.11.09

0

1

2

3

4

Wellbeing Problems F unctioning Risk

02.03.08

05.11.09

**’s CORE:**’s CORE:

StandardisStandardised ed measures measures like the like the CORE are CORE are proving proving less useful less useful with this with this client client group.group.

Inevitably, it will take time for us to

demonstrate the full economic benefits of this ‘invest to save’‘invest to save’

approach; but if we are given the opportunity to

survive long enough, you can be sure that we

will do so!

Why do I say that?Why do I say that?Because, in spite of all the evidence suggesting that personality-disorders are deserving and treatable

And a growing body of evidence demonstrating that treating PD leads to financial savings across all public sector services

We are still the ‘poor relation’ of M H services!In Fact, when it comes to allocation In Fact, when it comes to allocation of resources we’re as poor as church of resources we’re as poor as church

mice!mice!

Now I can set Now I can set up a Complex up a Complex Cases Service!Cases Service!

We’re a dynamic bunch of We’re a dynamic bunch of people and we keep battling people and we keep battling

on!on!

With the help of NIMHE & DoH we’ve made a promising start in breaking down

the barriers to P D exclusion, but is playing it NICENICE going to be enough?

BUTBUTAs long as the gains aren’t immediately observable

And scarce resources must be competed for

And it’s all about guidelines rather than targets

Will Trusts support this Will Trusts support this development?development?

And will Commissioners invest?And will Commissioners invest?

Complex Cases Team

OK guys; OK guys; it’s time to it’s time to get tough!get tough!

T N TT N T

TTrusts NNeed TTeamsTrinitrotoluene ? Trinitrotoluene ?

and maybe…… TTrusts rusts NNeed eed TTargets argets to encourage to encourage them to keep the P D agenda at the forefront of their them to keep the P D agenda at the forefront of their

minds!minds!

julie.machan@nhs.net

Dr Julie MachanConsultant Clinical PsychologistComplex Cases ServiceBirch Hill HospitalRochdaleOL12 9QB