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Complex Cases Service Rochdale Presents: ‘ 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! The
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 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.
Millie isn’t a real person But she may just as well be Because she represents so many of the women & men I’ve 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…….
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! “ They’re not really ill 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”
These ...isms are about PREDJUDICE! 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  the 1990’s and early 2000’s, 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!
NIMHE And came up with some bright new ideas BEWARE PARACHUTE D o H N I M H E Then, in 2001 arrived...
Personality Disorder: No longer a diagnosis of exclusion 2003 Let’s make
Then came those...
‘ NICE’   People
Which, together  with the NIMHE document, created the impetus for NHS Trusts to set up dedicated P D Teams With a set of Guidelines for BPD To address the following key priorities        
NICE Guidelines for BPD Assessment & treatment for the most complex & high risk clients Consultation & advice to other teams Help in the management of individual cases Facilitate good communication & 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 Complex Cases Service Pennine Care NHS Foundation Trust Fully operational since April 2008 2007 - Remit to develop a specialist PD Service (with  limited  resources):
 
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 we do and what have we 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 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 Validation
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 Attachment Social  Opportunities Environment   Socio-Economic  Circumstances  Culture & Religion  Cognitive Style Personal Psychology   Emotional Responsiveness Learned/Conditioned  Behaviours + Our FORMULTIONS are all UNIQUE to the INDIVIDUAL 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 thoughts  and  behaviours
That’s why, everything we do is driven by the formulation and NOT a diagnostic label
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 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 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
Client and Staff Feedback Questionnaires Have been administered to clients and MDT staff members with the following results: 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” 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”
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
Training Outcomes
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!
So we are auditing level of service use before, during and after involvement   with our team Incident reports Number of contacts with CRHT Police contacts Unplanned Psychiatry appointments Number / type of medical admissions Planned psychiatry appointments Visits to A & E In-patient days Contacts with Care  Co-ordinator M H admissions
 
 
 
Clinical Outcomes  (Client **) TARGET BEHAVIOURS To reduce: Staying in bed Drinking binges Brief, intense relationships Episodes of self-harm Social Isolation Angry, aggressive outbursts
**’s CORE: Standardised measures like the CORE are proving less useful with this client group.
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!
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 we’re as poor as church mice!
Now I can set up a Complex Cases Service!
The Complex Cases Team Mice we may be; deliver we have!
We’re a dynamic bunch of people and we keep battling 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  NICE  going to be enough? BUT As 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 development? And will Commissioners invest? We need more specialist teams
Complex Cases Team OK guys; it’s time to get tough!
T N T T rusts  N eed  T eams Trinitrotoluene ?  and maybe……   T rusts  N eed  T argets  to encourage them to keep the P D agenda at the forefront of their minds!
[email_address] Dr Julie Machan Consultant Clinical Psychologist Complex Cases Service Birch Hill Hospital Rochdale OL12 9QB

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NICE start, but is it time to get nasty? NICE Guidelines – how to implement them, audit them and use them for best benefit

  • 1. Complex Cases Service Rochdale Presents: ‘ 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! The
  • 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. 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:
  • 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 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.
  • 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 isn’t a real person But she may just as well be Because she represents so many of the women & men I’ve 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 Millie’s?
  • 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! “ They’re not really ill 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”
  • 10. These ...isms are about PREDJUDICE! Racism Sexism Ageism ‘ Diagnosticism’ They’re about: injustice unfairness intolerance discrimination misuse of power
  • 11. … 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
  • 12. But research during the 1990’s and early 2000’s, 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. NIMHE And came up with some bright new ideas BEWARE PARACHUTE D o H N I M H E Then, in 2001 arrived...
  • 14. Personality Disorder: No longer a diagnosis of exclusion 2003 Let’s make
  • 16. ‘ NICE’ People
  • 17. Which, together with the NIMHE document, created the impetus for NHS Trusts to set up dedicated P D Teams With a set of Guidelines for BPD To address the following key priorities   
  • 18. NICE Guidelines for BPD Assessment & treatment for the most complex & high risk clients Consultation & advice to other teams Help in the management of individual cases Facilitate good communication & 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
  • 19. Rochdale Complex Cases Service Pennine Care NHS Foundation Trust Fully operational since April 2008 2007 - Remit to develop a specialist PD Service (with limited resources):
  • 20.  
  • 21. 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
  • 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. 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 Validation
  • 26. Therapy rooms are made to feel welcoming and relaxing
  • 27.  
  • 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 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)
  • 31.                                                                                  Individual Genes Biology Neurochemistry Neuroanatomy Attachment Social Opportunities Environment Socio-Economic Circumstances Culture & Religion Cognitive Style Personal Psychology Emotional Responsiveness Learned/Conditioned Behaviours + Our FORMULTIONS are all UNIQUE to the INDIVIDUAL CLIENT                                                           
  • 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. That’s 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 member’s of their care team on board, with a unified ‘Multi-Agency 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
  • 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: 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” 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”
  • 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
  • 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 Incident reports Number of contacts with CRHT Police contacts Unplanned Psychiatry appointments Number / type of medical admissions Planned psychiatry appointments Visits to A & E In-patient days Contacts with Care Co-ordinator M H admissions
  • 41.  
  • 42.  
  • 43.  
  • 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 we’re 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. We’re a dynamic bunch of people and we keep battling on!
  • 51. 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 NICE going to be enough? BUT As 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 development? And will Commissioners invest? We need more specialist teams
  • 52. Complex Cases Team OK guys; it’s time to get tough!
  • 53. T N T T rusts N eed T eams Trinitrotoluene ? and maybe…… T rusts N eed T argets to encourage them to keep the P D agenda at the forefront of their minds!
  • 54. [email_address] Dr Julie Machan Consultant Clinical Psychologist Complex Cases Service Birch Hill Hospital Rochdale OL12 9QB