Putting the person back into person ality disorder

CALeaman North Staffordshire Combined Healthcare NHS Trust

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Putting the person back into personality

disorder

Improving services for people with Personality Disorder

Dr Christine Leaman

North Staffordshire Combined Healthcare NHS Trust


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Aims for today’s talk

Talk about developing a local service – Specially where there is no psychotherapy lead Insufficient funding/will to set up a therapy service

Can you do anything worthwhile that is less than a therapeutic service?


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Aims for today

Introduce myself and local service Describe method of setting up local service Refer to relevant evidence-base and

guidelines

Strengths and weaknesses of the model


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Who am I?

Consultant psychiatrist Practitioner in Cognitive Analytic Therapy

Work in a community mental health team in Stoke on Trent

And in a hub and spoke model Personality Disorder Service

Lately Clinical Director for Adult Services

Where is Stoke on Trent?


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Small, traditional Trust CAMHS, Adult and Older

People’s Services Learning Disability Services Joint health and social care

Trust Work with many partners in

local health economy Local service user’s group –

North Staffs Users Group


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Harplands Hospital – Community beds at 4

(out of 5) local Resource Centres

Adult services CMHT’s In-patients Crisis Home Treatment Functional teams

Used to have a therapeutic day service!


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Services for people with personality disorders … in 2004

Routine care Psychological therapies service –

Non-specialist for personality disorder Open to all service users

Care Programme Approach People with personality disorders struggled to get

appropriate care Out of area referrals for therapy

Main House – NHS regional therapeutic communtiy Private services


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What happened in 2003?

Drivers towards improving services for people with ‘personality disorders’ Increasing evidence of treatability for some

personality disorders Evidence re effective treatment models

In England & Wales DoH and NIMHE promotion of evidence-based

models

The impetus for developing services


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What happened regionally?

Regional Strategic Health Authorities were given central funding to promote development of personality disorder services A capacity plan A regional network – service users and

professionals Main House residential DTC The Olive Tree – one of the 11 pilot study

sites – day service


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Developing a local service - 2006

Meetings within the Trust Psychological therapies service Managers Clinical leaders Executives

Meetings with Commissioners Stoke and North Staffordshire

Meetings with service user groups


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What was the response?

Range of responses from bewilderment and disinterest to active encouragement

One set of Commissioners supportive So ... Audit of in-patient services

Nice Guidelines was not currently available Used Integrated Care Pathway to set standards Audit demonstrated significant short-falls in

current practice


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Developing a service – the principles

Evidence-base for what works Examples of good practice – a visit to The

Olive Tree - Local good will Regional network support

But Insufficient funds –


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Developing a service – the resources Funding from commissioners £ 44,000 for first year (subsequently £45,000

recurring) Psychological therapies input - 0.15 sessions per week (6

hours!) Part-time admin post 12 hours per week Part-time service user network co-ordinator 11 hours per

week Resources from within Trust

3 consultant sessions plus up to 4 sessions of an experienced senior nurse


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How does this compare with other services in the region?

Main House – tertiary and local service – closed in 2009

Birmingham & Solihull – therapeutic day service and hub and spoke model using ‘Stop and Think’

Coventry and Warwickshire – the Olive Tree therapeutic day service

Shropshire and South Staffordshire – lone worker doing education and awareness training

Several other small services eg DBT, MBT


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Think personality!

Putting the person back into personality disorder


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Core Team and Champions model

Innovative model Based on evidence and good practice

principles Adapted for local services Economical

But It has limitations It does not deliver a therapeutic service (yet)


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Core Team and Champion Model

CMHT

EIT

CIT

Rehab

AOT

IP teams

CMHT

CORE Team

Champion


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Core Team - membership

Management team: CAL Julie Elden Sue Imlack/Sheila

Sheltie Heather Creasey

Consultation team: CAL Julie Elden Karen Mason Carl Woolliscroft Christina Fitzgerald Cat O’Callaghan

Graham Breeze – independent supervisor


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What does the team do?

Consultation to NSCHT teams and to partnership organisations

Education and awareness training Service user forum Carer forum

Put the person back into personality disorder!


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What does the team do?

A lot of (self)-promotion eg Link on Trust web-site Entered for Trust Innovation competition Survey Monkey survey to staff On the Trust training programme Attend local health and social care economy

meetings Links with third sector organisations World Mental Health Day, hosting a local

conference …. logo competition …


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What else does the team do

Data collection Consultations

Immediate satisfaction feedback Data on service use by consultation – historical and

prospective use of CRHT, in-patient bed days, number of admissions etc

Education and training feedback Current audit of CMHT management of

people with personality disorder (in line with Nice Guideline)


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The Personality Disorder ServicePutting the Person back into

Personality Disorder

The NSCHT PDS main functions

Consultation to teams Service user involvement Education and awareness training


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Consultation is ...

A widely used model for developing good practice Professionals’ meeting with PD Core Team input A space to reflect To address difficult issues To contribute to care-planning To develop team ownership of care-plans for

complex needs To share positive risk-taking


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Consultation

What is consultation?

A consultation is a professionals’ meeting of all involved individuals, meeting together with members of the Core team, to discuss & think about the service user, their needs, the challenges for the team and individual staff members of working with them, with the aim of using a more informed understanding to develop care planning, risk management and positive strategies


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What makes a good consultation?

Time – usually 90 minutes Attendance – best results if all the people

involved face-to-face can be there Supported by managers Augmented by representatives from other

agencies or teams Acting in – everyone’s impressions and

contributions are valuable


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Consultation activity – year one

Total number of consultations: 23 Total number of service users: 19

2 clients had one follow-up consultation 1 client had two follow-up consultations


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Consultation occurrences

0

1

2

3

4

5

Apr-08

May-08

Jun-08

Jul-08 Aug-08

Sep-08

Oct-08

Nov-08

Dec-08

Jan-09

Feb-09

Mar-09

Consultations, incl. F-Ups


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Numbers Present at Consultations

0

1

2

3

45

6

7

89

10

11

1 - 3 4 - 6 7 - 9 Mode: 3

Numbers Present


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Themes – what was useful?

‘professional and objective discussion and outcomes’ ‘Helped to refocus and clarify needs of client’

‘supervision element helped to identify patterns of behaviour and also suggestions regarding how to progress’ Multidisciplinary discussion and ‘outside

perspective’’ ‘reaffirming current input is appropriate’


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Themes – what was least useful?

‘No further treatment strategies identified to help with management of client because all available options have been offered and tried’ ‘that the Core Team were unable to give ‘the

answer’’ Feelings that the interventions for PD ‘are so

ineffective’ ‘there are no easy answers on how to care for this

type of client’ ‘the client may sabotage outcomes’


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Team Feedback – Core Team

Was the Consultation Useful?

None 0/21

Very 3/21

Some 6/21

Quite 12/21

Core Team feedback


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Feedback – Comparison

0123456789

101112

Some Quite Very

Core TeamCare Coordinator / Team


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Could the Core Team identify features of a personality disorder in the patient?

Features of PD identified in patient (based on Core Team’s feedback) 17/19

Cluster A: 1

Cluster B: 14

Cluster C: 3


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Consultations feedback

Useful to be listened to All team members contributed Recognition of ongoing risks No short-term solution Looked at joint working Supportive, non-judgmental approach Off-load main concerns, feelings & frustrations Empowerment of client


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Core Team analysis

Main problems brought by the MDT Patient disengagement or lack of taking

responsibility Professional conflict within team Escalating risk Lack of support for Care Co-ordinator Pressure from carers/family/other agencies Splitting Boundary issues


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Core Team analysis

Main problems brought by the MDT ? referral to therapeutic service or another team

(eg rehab or assertive outreach) Issues re MDT’s shared understanding and

communication issues Unrealistic expectations eg re time-scale Feeling stuck and pessimistic re outcome Staff needing reassurance


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As discussed in Core Team supervision ... Underlying issues Lone Care Co-ordinator

getting tired Team splitting Needs of service user not

central Information not being

considered Unrealistic aims Emotional responses not

being recognised No team discussion

Positive outcomes Improved

communication Shared risk

management Person-centred

approach Involving service user

more in planning


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Main agreed outcomes

Increased support for the Care Co-ordinator Information sharing within consultation Clarity for team members about their roles Confirming principles of working with people

with PD Eg setting boundaries Shared management of risk Communication Using team supervision


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In summary

Re consultations Consultations are being requested for the right

client group The feedback is that the consultations are positive

and useful Repeat consultations are often useful – specially

for teams struggling with strong emotions evoked by working with PD clients

Some teams require/request increased training


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Setting up the Core Team …

Core Team – 3 workshop days with external trainers Team-building, agreeing principles, finding a

common theoretical framework Supervision (with an independent supervisor) Ongoing training – external and internal –

some jointly with Champions Theoretical, practical – eg developing training

skills


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A very simple model of borderline pd

Borderline pd occurs in people who have early difficulties (before age 3 – attachment difficulties) PLUS trauma in childhood

They have disrupted development They have difficulties in managing their emotions,

having a sense of self, impulse control, relationships (specially trust)

Everyone gets stuck in repeating patterns of behaviour – for people with personality disorder this can be more harmful and more difficult to change


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Treatment models – the principles

Accessibility Flexibility Consistency A coherent theoretical model Supervision Consultation Education


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Nice Guidance for Borderline Personality

Disorder

Treatment & management

Issue date Jan 2009

Developed by National Collaborating Centre for Mental Health

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The Personality Disorder ServicePutting the Person back into

Personality Disorder


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The Champion network

What is a Champion?

Interested in working with PD people

One of more in each team

Extra training with Core Team mandatory

‘Champion’ PD

Liaise with Core Team- practical role

Can develop skills further – on the training escalator


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PD Champion role

Help teams to Think Personality! Help care co-ordinators think about benefits

of consultation Help arrange consultations Be a link with the Core Team Training – for Champions and with Core

Team Support network


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Selecting champions

One to one interviews Agreement with line manager to release time

for working with PDS and to go to Champions network and training

Champions network meets monthly Ongoing training opportunities – external and

internal Commitment to three training sessions in first

year and two thereafter


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The Champions

22 in 13 teams – CMHT’s, IP wards, CRT, functional teams, SW duty team All disciplines People who volunteer Have an interest in PD Want to learn more Want to develop skills


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The Service User Network

Service user forum - aims To develop awareness of personality disorder

locally among service users To inform re local services and opportunities for

development To contribute to service development To contribute to planning and delivery of

awareness training and education

Potentially to become a supportive network


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Service User Network

Run by service user network co-ordinator Monthly meetings in a non-NHS setting Wide publicity Agenda set each session

Successful launch day in January 2009 Developing a newsletter to go out in The Voice Contributing to Trust PPI days Participants in KUF training

Quarterly carers’ meetings


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What else does the team do?

Education and awareness training: Education – to MDT’s, services and professional

groups Training – to partnership organisations Undergraduate and postgraduate teaching Professional groups Primary care

All training opportunities are taken up All Core Team members contribute


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Training developments

Champion training on-going Penetration to other teams Delivery of further training in NSCHT

understanding causes of BPD attachment what works in teams ‘Feeling shattered – dealing with ‘splitting’’ Using supervision

Trust training programme


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Knowledge & Understanding Framework for PD

DOH sponsored scheme Developed by a consortium

Personality Disorder Institute (Pdi) at Nottingham University Tavistock & Portman NHS Trust Borderline UK (part of Emergence CIC) Open University

Training escalator – from basic awareness to doctorate level training re personality disorder

Awareness training – e-learning supported by a virtual learning environment & local training by teams

West Midlands KUF

Three PD Services won tenders to deliver Awareness level training Birmingham, Coventry and Warwick and NSCHT Personality Disorder Virtual Learning Awareness

(VLA) Programme 6 e-learning modules Supported by 3 experiential workshop days –

jointly led by a professional and a service user Currently training to deliver in 2010-2011


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In summary

Our aim remains to develop a therapeutic day service

In the meantime we have a service which delivers parts of the Nice Guideline recommendations Education and awareness training It supports CMHT’s in delivering Nice Guideline It supports the organisation in delivering Nice

Guideline


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In summary

We have put together an effective Core Team which is ready to develop a therapeutic service

We have a service user forum which makes links locally and regionally

We have increasingly well-trained staff who are able to ‘champion’ personality disorder service user needs ...


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Think personality!

Putting the person back into personality disorder

Documents

Putting the person back into person ality disorder