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Putting the person back into person ality disorder

Putting the person back into person ality disorder. Improving services for people with Personality Disorder Dr Christine Leaman North Staffordshire Combined Healthcare NHS Trust . Aims for today’s talk. Talk about developing a local service –

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Putting the person back into person ality disorder

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  1. Putting the person back into personality disorder Improving services for people with Personality Disorder Dr Christine Leaman North Staffordshire Combined Healthcare NHS Trust North Staffordshire Combined Healthcare NHS Trust

  2. 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? North Staffordshire Combined Healthcare NHS Trust

  3. 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 North Staffordshire Combined Healthcare NHS Trust

  4. 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 North Staffordshire Combined Healthcare NHS Trust

  5. Where is Stoke on Trent? North Staffordshire Combined Healthcare NHS Trust

  6. North Staffordshire Combined Healthcare NHS Trust • 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 North Staffordshire Combined Healthcare NHS Trust

  7. North Staffordshire Combined Healthcare NHS Trust • 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! North Staffordshire Combined Healthcare NHS Trust

  8. 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 North Staffordshire Combined Healthcare NHS Trust

  9. 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 North Staffordshire Combined Healthcare NHS Trust

  10. The impetus for developing services North Staffordshire Combined Healthcare NHS Trust

  11. 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 North Staffordshire Combined Healthcare NHS Trust

  12. 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 North Staffordshire Combined Healthcare NHS Trust

  13. 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 North Staffordshire Combined Healthcare NHS Trust

  14. 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 – North Staffordshire Combined Healthcare NHS Trust

  15. 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 North Staffordshire Combined Healthcare NHS Trust

  16. 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 North Staffordshire Combined Healthcare NHS Trust

  17. Think personality! Putting the person back into personality disorder North Staffordshire Combined Healthcare NHS Trust

  18. 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) North Staffordshire Combined Healthcare NHS Trust

  19. Core Team and Champion Model Champion North Staffordshire Combined Healthcare NHS Trust

  20. 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 Core Team - membership North Staffordshire Combined Healthcare NHS Trust

  21. 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! North Staffordshire Combined Healthcare NHS Trust

  22. 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 … North Staffordshire Combined Healthcare NHS Trust

  23. 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) North Staffordshire Combined Healthcare NHS Trust

  24. The Personality Disorder Service Putting the Personback into Personality Disorder North Staffordshire Combined Healthcare NHS Trust

  25. The NSCHT PDS main functions • Consultation to teams • Service user involvement • Education and awareness training North Staffordshire Combined Healthcare NHS Trust

  26. 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 North Staffordshire Combined Healthcare NHS Trust

  27. 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 North Staffordshire Combined Healthcare NHS Trust

  28. 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 North Staffordshire Combined Healthcare NHS Trust

  29. 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 North Staffordshire Combined Healthcare NHS Trust

  30. Consultation occurrences North Staffordshire Combined Healthcare NHS Trust

  31. Numbers Present at Consultations North Staffordshire Combined Healthcare NHS Trust

  32. 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’ North Staffordshire Combined Healthcare NHS Trust

  33. 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’ North Staffordshire Combined Healthcare NHS Trust

  34. Team Feedback – Core Team Was the Consultation Useful? None 0/21 Some6/21 Quite12/21 Very3/21 Core Team feedback North Staffordshire Combined Healthcare NHS Trust

  35. Feedback – Comparison North Staffordshire Combined Healthcare NHS Trust

  36. 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 North Staffordshire Combined Healthcare NHS Trust

  37. 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 North Staffordshire Combined Healthcare NHS Trust

  38. 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 North Staffordshire Combined Healthcare NHS Trust

  39. 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 North Staffordshire Combined Healthcare NHS Trust

  40. 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 As discussed in Core Team supervision ... North Staffordshire Combined Healthcare NHS Trust

  41. 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 North Staffordshire Combined Healthcare NHS Trust

  42. 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 North Staffordshire Combined Healthcare NHS Trust

  43. 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 North Staffordshire Combined Healthcare NHS Trust

  44. 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 North Staffordshire Combined Healthcare NHS Trust

  45. Treatment models – the principles Accessibility Flexibility Consistency A coherent theoretical model Supervision Consultation Education North Staffordshire Combined Healthcare NHS Trust

  46. Nice Guidance for Borderline Personality Disorder 78 Treatment & management Issue date Jan 2009 Developed by National Collaborating Centre for Mental Health North Staffordshire Combined Healthcare NHS Trust

  47. The Personality Disorder Service Putting the Personback into Personality Disorder North Staffordshire Combined Healthcare NHS Trust

  48. 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 North Staffordshire Combined Healthcare NHS Trust

  49. 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 North Staffordshire Combined Healthcare NHS Trust

  50. 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 North Staffordshire Combined Healthcare NHS Trust

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