Complex Cases Service Rochdale Presents

1
Complex Cases ServiceRochdalePresents
The

• NICE start, but is it time to 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!

2
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!
3
Millies 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
4
(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 Millies brain was
compromised, because poor attachment between an
infant and its primary caregivers, leads to poor
attachment between the brains 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.
5
By the time Millie went to school, she felt
unlovable and struggled to have normal
relationships. Her rapidly changing and
extreme 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.
6

• Millie isnt a real person

• But she may just as well be

• Because she represents so many of the women men
  Ive worked with over the years

• Not only has she been neglected and rejected by
  her family, peers and teachers, Mental Health
  Services have continued to treat her in this
  manner.

7
Who would choose to have a life like Millies?
8
Yet historically, the attitude of mental health
services has been to blame people like Millie for
their own situation!
9
Millie, like so many others with Personality
Disorder, has been a victim of
Diagnosticism!
Theyre just messing about arent they
Its not like schizophrenia is it People cant
help having that!
Theyre not really ill are they
If theres two people on the ward saying theyre
going to kill themselves, who are you going to go
to, the person whos really ill, or the one whos
just p-----g about?
They should pull themselves together and stop
wasting precious time and resources
10
Racism Sexism Ageism
Diagnosticism
These ...isms are about PREDJUDICE!

• Theyre about
• injustice
• unfairness
• intolerance
• discrimination
• misuse of power

11
and about excluding people from their right to a
fair share of societys resources!
And until 6 years ago Diagnosticism was used to
deny people with PD the treatment they needed and
deserved
12
But research during the 1990s
and early 2000s, sewed the seeds for a change in
attitude evidence began to accumulate about the
biological, psychological and social causes of
personality disorder and about its treatability.
People with PD who wanted help, could no longer
be ignored!
13
Then, in 2001
NIMHE
arrived...
PARACHUTE
M
H
I
E
D o H
N
BEWARE
And came up with some bright new ideas
14

Lets make
Personality Disorder No longer a diagnosis of
exclusion 2003
15
Then came those...
16

NICE People
17
With a set of Guidelines for BPD
Which, together with the NIMHE document, created
the impetus for NHS Trusts to set up dedicated P
D Teams
To address the following key priorities ? ? ?
18
Provision of longer-term, evidence-based
therapies
Assessment treatment for the most complex
high risk clients
Consultation advice to other teams
Oversee the implementation of NICE guidance
NICE Guidelines for BPD
Help in the management of individual cases
Develop provide training programmes
Facilitate good communication information
sharing
Networking with other agencies, including,
forensic, CAMHS, Social Care
19
2007 - Remit to develop a specialist PD Service
(with limited resources)
Rochdale Complex Cases Service
Pennine Care NHS Foundation Trust Fully
operational since April 2008
20
(No Transcript)
21
The Hub Team

• Clinical Lead / Consultant Clinical Psychologist
• Operational Manager / Senior M H Nurse
• Clinical Psychologist
• Psychology Assistant
• Skills Therapist / M H Nurse
• AC

22
So what do we do and what have we achieved?
23
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.)

24
Role 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

25
The Importance of Validation

• 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..

26
Therapy rooms are made to feel welcoming and
relaxing
27
(No Transcript)
28
We have placed maximum effort into developing
high quality information leaflets taking advice
from service user representatives
29
The same applies to our Skills-Based Therapy
handouts which have been carefully thought
through and made as accessible and user-friendly
as possible
30

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

• We ensure that we explain all aspects of whats
  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

31
Our FORMULTIONS are all UNIQUE to the INDIVIDUAL
CLIENT
                                               
                                
Individual Genes Biology
Neurochemistry
Neuroanatomy



Attachment Social
Opportunities Environment
Socio-Economic

Circumstances
Culture
Religion
Cognitive
Style Personal Psychology
Emotional
Responsiveness
Learned/Conditioned
Behaviours


32
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 thoughts and behaviours
33
Thats why, everything we do is driven by the
formulation and NOT a diagnostic label
34

• Working within the Care Programme Approach (CPA),
  we aim to bring all other members of their care
  team on board,

• with a unified Multi-Agency Management Plan (a
  M-AMP), based on the formulation
• This approach places the clients 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

35
Therapeutic Interventions

• 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
• 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

36
Client and Staff Feedback Questionnaires

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

• Staff
• Information 12/15
• Involvement 4/5
• Formulation Feedback 17/30
• M-AMPs 17/20
• Consultation Supervision 9/10
• Effectiveness of therapy 8/10
• Other Comments
• Provides a safe, accountable framework
• for managing risk in the community
• Needs more clinicians

• Clients
• Environment 15/20
• Clinicians 25/30
• Information 12/15
• Therapy Handouts 18/20
• Other Comments
• Very helpful, but hard
• Too much noise in the
• corridor
• A brew would help

37
Training Events

• 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 interest
  and enthusiasm for working with people with
  personality-related mental health difficulties
• We want staff to feel greater confidence and
  competence to work with clients with complex
  presentations
• Above all, we aim to increase compassion and
  empathy for our clients, so that they feel valued
  and listened to

38
Training Outcomes
39
We are in for the long-haul, interested in
providing quality services to our clients, but
this high intensity approach requires
justification if we are to survive in the current
economic climate!
40
So we are auditing level of service use before,
during and after involvement with our team
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
Clinical Outcomes (Client )

• TARGET BEHAVIOURS
• To reduce
• Staying in bed
• Drinking binges
• Brief, intense relationships
• Episodes of self-harm
• Social Isolation
• Angry, aggressive outbursts

45
s CORE
Standardised measures like the CORE are proving
less useful with this client group.
46
Inevitably, it will take time for us to
demonstrate the full economic benefits of this
invest to save approach but if we are given
the opportunity to survive long enough, you can
be sure that we will do so!
47
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 of resources
  were as poor as church mice!

48
Now I can set up a Complex Cases Service!
49
The Complex Cases Team
Mice we may be deliver we have!
50
Were a dynamic bunch of people and we keep
battling on!
51
With the help of NIMHE DoH weve made a
promising start in breaking down the barriers to
P D exclusion, but is playing it NICE going to be
enough?
We need more specialist teams

• BUT
• As long as the gains arent immediately
  observable
• And scarce resources must be competed for
• And its all about guidelines rather than targets
• Will Trusts support this development?
• And will Commissioners invest?

52

OK guys its time to get tough!
Complex Cases Team
53
T N T
Trinitrotoluene ?
Trusts Need Teams
and maybe Trusts Need Targets to encourage them
to keep the P D agenda at the forefront of their
minds!
54
julie.machan_at_nhs.net Dr Julie
Machan Consultant Clinical Psychologist Complex
Cases Service Birch Hill Hospital Rochdale OL12
9QB