ACT Senior Practitioner Seminar

1. 31 May 2019 Dr Angela Livingstone Psychiatrist Victorian Dual Disability Service ACT Senior Practitioner Seminar

2. Establishment of the Victorian Dual Disability Service • Context: • Late 1990’s – State Mental Health Branch recognised that the needs of those Victorians with a Dual Diagnosis (intellectual disability AND a mental illness) were not being adequately met through either the Disability or Mental Health Services system • Joint tender between the mental health programs of St Vincent's and Melbourne Health. • VDDS established in March 1999 to work as an adjunct to the 21 AMHS (area-based mental health catchments) • Based at St Vincent’s but state-wide service

3. Extended Regional Service Response • 45 assessments provided per year to people registered with Disability/NDIS, not involved with AMHS. • Training to Disability Service providers • Funded initially by Disability Services, funding now more precarious. Footnote to go here

4. MHIDI • Pilot in two mental health service areas – community based specialist led assessment and treatment service for dual disability • Closer to ACT model: • Specialist input after work-up by other clinicians (nursing, social work, OT, psychologist etc.) • Able to provide case management over time. Footnote to go here

5. Target Population Eligibility Victorians aged 16 years and over; • Current consumers of State funded area mental health services with a known or suspected serious mental illness

6. Service Provision • Clinical • Provide diagnostic clarification & management recommendations to AMHS. • Training • Provide training and education (primarily to AMHS staff) • Service Development • Tertiary consultations • Research • Conference presentations • Publications

7. Training Purpose: • Increase the capability and competency of staff employed by AMHS in assessing and managing mental disorders in Victorians with a known or suspected intellectual disability. Form • Information sessions about the Service on request • Consumer specific training (assisting case managers to create and implement management plans) • Conferences • Workshops for AMHS staff including modules on Challenging Behaviours, Personality Disorders and ASD.

8. VDDS • Psychiatrists • Chad Bennett (Director) 0.8 FTE • Tareq Abuelroos 0.8 FTE • Angela Livingstone 0.6 FTE • Nurse Practitioner • Andrew Pridding 1.0 FTE • Administration 1.0 FTE • Manager 0.4

9. Angela Livingstone • Worked at the Victorian Office of the Chief Psychiatrist analysing the statewide register of seclusion. • Completed a Dissertation on seclusion practices in Victoria and a Report to the Chief Psychiatrist’s Quality Assurance Committee • Seclusion in Victoria, 2002 • Started working at VDDS in 2007 and commissionedto complete literature review on restrictive practices for the Victorian Office of the Senior Practitioner • Creating Safety: Addressing Seclusion and Restraint Practices project: Literature review. 2007 • Co-presented 3 RANZCP e-Learning modules on Intellectual disability: Prescribing psychotropic medication for patients with an intellectual disability, 2013 • Designed, implemented and maintained a Dual Disability Web resource for direct care workers including a module on challenging behaviours, 2013 Footnote to go here

10. Restrictive practice elimination • Requirements: • Asufficiently skilled workforce (funding and training implications) • With capacity to implement positive behaviour support (funding, supervision, management). • With training in trauma-informed care. • With capacity to provide trauma-informed care. • An independent complaints mechanism • With capacity to respond to people with disability who are experiencing challenging behavior (no wrong door, disability friendly, ideally Commonwealth-wide and pathways aligned with the States and Territories) Footnote to go here

11. Restrictive Practices – Governance Issues • National Framework for Reducing and Eliminating the Use of Restrictive Practices in Disability Services Sector (2014) – provides a platform and some structure for national consistency. • Outlines ‘how’ and ‘when’ to use restrictive practices. • Does not address prevention and early intervention. • Designed for use by disability services only. • Does not address the issue of restrictive practices in mainstream services (schools, hospitals, mental health services, Child Protection, families and the Justice system. • Governance for administering and monitoring the use of restrictive practices in Australia currently falls under state and territory jurisdictions, with significant variation. Footnote to go here

12. Trauma and ID • People with ID are more likely to experience trauma. • Why? • Vulnerable to abuse (physical, emotional, sexual) and neglect • Between 2.5 and 10 times more likely – higher risk in institutional settings, more than one disability, more severe disability • More severe/prolonged abuse • less able to report, less likely to be believed • Trauma and abuse may also be the cause of disability or additional disability Footnote to go here

13. Vulnerabilities to abuse • Higher level of assistance from caregivers • For longer periods of time • For invasive daily living functions • Higher level of stress on the family/caregivers • Less able to meet parental/caregiver expectations • Decreased ability to predict high-risk situations • May not understand what is happening in an abusive situation • Increased responsiveness to attention and affection (easier to manipulate) • Less likely to be provided with sex education • Caregiver’s assumption that they are asexual • Charlton, Kliethermes, Tallant, Taverne, & Tishelman (2004) Footnote to go here

14. Barriers to reporting • Mobility challenges • Restricted ability to communicate • Dependent on abusers • Not perceived as credible reporters • Trained to be compliant to authority figures • Charlton, Kliethermes, Tallant, Taverne, & Tishelman (2004) Footnote to go here

15. Not just abuse • Normal range of traumatic events and experiences • grief, • loss, • natural disasters, • accidents, • medical procedures/illness/loss of function • witnessing abuse, • moving house, • migration/refugee status • losing friends, • seeing others progress in life • etc. • Effect of these may be missed/minimized or misdiagnosed. Footnote to go here

16. How can trauma present? • Complex developmental trauma will affect the developing personality. Relationships may be fragile, labile or overinvested in. Choice of partners may be affected by trauma. Attitude to other people (esp. authority figures) may be affected. • Response to acute stress (amygdala hijack): • Fight • Fight • Freeze • Discrete traumatic events may result in the usual range of post-traumatic reactions: • sleep disturbance, • startle response, • Numbing/emotional constriction, • disrupted sense of safety, • shattered self-identity, etc. • vulnerability to mental illness Footnote to go here

17. How can trauma present? • Challenging behaviours. • Aggression (verbal/physical) • Restlessness / overactivity / intrusiveness • Property damage • Self harm / suicidality • Regression • Withdrawal • Inappropriate sexualized behaviours • Substance abuse • Overeating/other eating problem • etc. • Hyperarousal vs hypoarousal Footnote to go here

18. Diagnostic Overshadowing • This can happen when a response to trauma is attributed to other conditions: • Disability • Mental illness • Personality • Choice • (obviously where there are disability needs, personality disorder, predatory criminal behaviour or mental illness these also need to be addressed) Footnote to go here

19. Inadvertent consequences • No treatment • Wrong treatment (antipsychotics etc.) • Victim blaming • Restrictive Practices Footnote to go here

20. Assessment of trauma • Trauma assessments are not investigations • Assessment and treatment are about perceptionsnot necessarily about facts of what happened • Psychoeducation of caregivers is an essential part of ongoing assessment Footnote to go here

21. Assessment of trauma • Trauma History • • Presenting trauma and its important characteristics • • All other traumas • Mental Health Symptoms and Behavior Problems • • History and current symptoms • Environment • • Safety, support, individual-caregiver relationship • • System involvement with family/caregivers since abuse • Characteristics of Trauma • • Frequency, chronicity, perpetrator/relationship, disclosure and response • • Legal involvement Footnote to go here

22. Trauma informed care • A trauma informed service works to notre-traumatisethe person. • Recognisesthe prevalence of trauma • Focuses on what has happened rather than what is ‘wrong’ with a person • Understands and is responsive to the impact of trauma • Emphasisessafety, power and control for survivors • Recognisesthe importance of relationships as a means of promoting healing and recovery • Promotes safe environments: physical, emotional, moral and cultural • Minimisesthe potential for re-traumatisation • Emphasisesa recovery orientation Footnote to go here

23. Restrictive practice elimination • Requirements: • Asufficiently skilled workforce (funding and training implications) • With capacity to implement positive behaviour support (funding, supervision, management). • With training in trauma-informed care. • With capacity to provide trauma-informed care. • An independent complaints mechanism • With capacity to respond to people with disability who are experiencing challenging behavior (no wrong door, disability friendly, ideally Commonwealth-wide and pathways aligned with the States and Territories) Footnote to go here

24. Resources • https://www.ranzcp.org/publications/e-learning • This is an e-learning module funded by the Senior Practitioner in Victoria, aimed at upskilling psychiatrists and GPs in assessing and managing people with an ID and mental illness. • https://www.blueknot.org.au/ • National Centre of Excellence for Complex Trauma • http://www.disabilityjustice.edu.au/resources • Has training resources on trauma and disability • https://www.childhoodinstitute.org.au/sites/default/files/2018-05/Taking-Time-Framework.pdf • A framework for supporting people with intellectual disability and complex trauma. Footnote to go here