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!
Dr Julie MachanConsultant Clinical PsychologistComplex Cases ServiceBirch Hill HospitalRochdaleOL12 9QB