nice start, but is it time to get nasty? nice guidelines – how to implement them, audit them and...

8/9/2019 NICE start, but is it time to get nasty? NICE Guidelines – how to implement them, audit them and use them for best benefit

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10/02/2009

Complex Cases

ServiceRochdalePresents:

‘ 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 adiagnosis of BPD and

has been in and out of psychiatric hospitals

since the age of 14!



Millie’s parents were harsh andneglectful. 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 lefther crying in hunger and distress. Theydid not interact with her and would hither if she protested too much about her discomfort. For Millie, this had 2 directconsequences:



(1). Millie learned that the world was hostile andunpredictable and that people are cruel and notto 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 thebrain’s emotion production centre and its emotionregulation and problem-solving centres. In practice, thismeant that Millie experienced extreme and rapidly

changing emotions, without being able to exercise controlover them or problem-solve her way out of the crises thattriggered the emotions.



By the time Millie went to school, she feltunlovable and struggled to have normalrelationships. Her rapidly changing and

extreme moods made her unpopular with everyone, asshe would either lash out at other children or cut herself off and refuse to play with them. She wanted to fit in, buthad no idea how to make others like her. She ended upbeing bullied by her peers. The teachers were highlycritical, 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 beingalive was so emotionally painful, she used alcohol,drugs, cutting and overdosing to try and block out thehurt.



• Millie isn’t a real person

• But she may just as well be

• Because she represents so manyof 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 HealthServices have continued to treather in this manner…….



Who wouldchoose to

have a lifelike

Millie’s?



Yet historically, theattitude of mental

health services has

been to blamepeople like Millie for their own situation!



Millie, like so many others with‘Personality Disorder’, has been a victim of:

Diagnosticism!

“They’re not really illare they”

“They’re just messingabout aren’t they”

“It’s not like schizophrenia is it;People can’t help having that!

“If there’s two people on the wardsaying they’re going to kill

themselves, who are you going to goto, the person who’s really ill, or the

one who’s just p-----g about?”

“They should pull themselvestogether and stop wastingprecious time and resources”



RacismSexism

Ageism‘Diagnosticism’

They’re about:• injustice• unfairness

• intolerance• discrimination• misuse of power



…and about excludingpeople from their right

to a fair share of society’s resources!

And until 6 years ago ‘Diagnosticism’was used to deny people with PD thetreatment they needed and deserved



But research during the 1990’sand early 2000’s, sewed theseeds for a change in attitude;evidence began to accumulate

about the biological,psychological and social causesof personality disorder and about

its treatability. People with PD

who wanted help, could nolonger be ignored!



And came upwith somebright new

ideas



Personality Disorder:No longer a diagnosis

of exclusion2003

Let’s make



‘NICE’ People



Which, together withthe NIMHE document,

created the impetusfor NHS Trusts to set

up dedicated P D

Teams

With a set of Guidelines for BPD

To address the following key priorities



NICEGuidelines

for BPD

Assessment &treatment for themost complex &

high risk clients

Consultation &advice to other

teams

Help in themanagementof individual

cases

Facilitate goodcommunication &

informationsharing

Networking with other agencies, including, forensic,

CAMHS, Social Care

Provision of longer-term,evidence-

basedtherapies

Develop & providetraining programmes

Oversee the

implementation of NICE guidance



RochdaleComplex Cases

Service

Pennine Care NHS Foundation Trust

Fully operational since April 2008

2007 - Remit to develop a specialist PD Service (withlimited 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 dowe do and

what have weachieved?



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 clientshave 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 andrespect them

• We try to send out this message in anumber of different ways……..

The Importance of Validation



Therapy rooms are made to feel welcoming and relaxing



We have placed maximum effortinto developing high quality

information leaflets taking advicefrom service user representatives



The same applies to our Skills-BasedTherapy handouts which have been

carefully thought through and made asaccessible and user-friendly as

possible



• We ensure that we explain all aspects of what’son offer in a clear, unambiguous manner so our clients are empowered to make decisionsabout their own treatment

• With their consent, we make sure that we trackdown and review all their available mentalhealth, health and social care records

• All of this information is combined into a

biopsychosocial formulation, which drawson 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)

Our FORMULTIONS are all UNIQUE to the



Individual Genes

BiologyNeurochemistryNeuroanatomyAttachment

Social Opportunities

Environment Socio-EconomicCircumstances

Culture & ReligionCognitive Style

Personal

Psychology Emotional ResponsivenessLearned/ConditionedBehaviours

+

Our FORMULTIONS are all UNIQUE to theINDIVIDUAL CLIENT



We believe it is hugelyimportant to tailor our service

to each individual client, and towork collaboratively with themto try and make sense of their

journey through life, and how ithas resulted in them beingstuck in patterns of self-

defeating thoughts andbehaviours



That’s why,everything we do

is driven by theformulation andNOT a diagnostic

label



• Working within the Care ProgrammeApproach (CPA), we aim to bring all other member’s of their care team on board,

with a unified ‘Multi-Agency Management Plan’ (aM-AMP), based on the formulation

• This approach places the client’s needs at the

heart of the intervention and is designed topromote consistency and safe containment fromthe care team

• We monitor the implementation of the M-AMP viathe 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 theindividual to have real choice about how to live their livesin 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 thebiological, psychological and social origins of personalityand 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 withpersonality-related mental health difficulties

• We want staff to feel greater confidence andcompetence to work with clients with complex

presentations• Above all, we aim to increase compassion and empathyfor our clients, so that they feel valued and listened to



Training Outcomes



We are in for the long-haul,interested in providingquality services to our

clients, but this highintensity approach requires

justification if we are tosurvive in the current

economic climate!



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

M H admissions Contacts with CareCo-ordinator

In-patient days Visits to A & E

Planned psychiatryappointments

Number / type of medicaladmissions

Unplanned Psychiatryappointments

Police contacts

Number of contacts with CRHT Incident reports



Clinical Outcomes (Client **)

TARGETBEHAVIOURS

To reduce:• Staying in bed• Drinking binges•

Brief, intenserelationships• Episodes of self-

harm• Social Isolation• Angry, aggressive

outbursts



**’s CORE:

Standardisedmeasures likethe CORE are

proving lessuseful withthis clientgroup.



Inevitably, it will take time

for us to demonstrate thefull economic benefits of this‘invest to save’ approach;

but if we are given theopportunity to survive longenough, you can be sure

that we will do so!



Why do I say that?

• Because, in spite of all the evidencesuggesting that personality-disordersare deserving and treatable

• And a growing body of evidencedemonstrating that treating PD leadsto financial savings across all publicsector services

• We are still the ‘poor relation’ of M Hservices!

• In Fact, when it comes to allocation of resources we’re as poor as church mice!



Now I can set up aComplex Cases

Service!



We’re a dynamic bunch of peopleand we keep battling on!

With th h l f NIMHE & D H ’ d



With the help of NIMHE & DoH we’ve made apromising start in breaking down the barriers toP 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 targetsWill Trusts support this development?And will Commissioners invest?



ComplexCasesTeam

OK guys; it’stime to get

tough!



T N T

Trusts Need Teams

Trinitrotoluene ?

and maybe…… Trusts Need Targets to encourage them tokeep the P D agenda at the forefront of their minds!



[email protected]

Dr Julie MachanConsultant Clinical PsychologistComplex Cases ServiceBirch Hill HospitalRochdale

OL12 9QB

nice start, but is it time to get nasty? nice guidelines – how to implement them, audit them and...

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