Complex Cases Service Rochdale Presents:

1. The 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!

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 just messing about aren’t they” “It’s not like schizophrenia is it; People can’t help having that! “They’re not really ill are they” “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. Racism Sexism Ageism ‘Diagnosticism’ These ...isms are about PREDJUDICE! • 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. Then, in 2001 NIMHE arrived... PARACHUTE M H I E D o H N BEWARE And came up with some bright new ideas

14. Let’s make Personality Disorder: No longer a diagnosis of exclusion 2003

15. Then came those...

16. ‘NICE’People

17. With a set of Guidelines for BPD Which, together with the NIMHE document, created the impetus for NHS Trusts to set up dedicated P D Teams To address the following key priorities   

18. Provision of longer-term, evidence-based therapies Assessment & treatment for the most complex & high risk clients Consultation & advice to other teams Oversee the implementation of NICE guidance NICE Guidelines for BPD Help in the management of individual cases Develop & provide training programmes Facilitate good communication & information sharing Networking with other agencies, including, forensic, CAMHS, Social Care

19. 2007 - Remit to develop a specialist PD Service (with limited resources): Rochdale Complex Cases Service Pennine Care NHS Foundation Trust Fully operational since April 2008

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: • ENDURINGmental 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) • HighRISK 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. The Importance of Validation • 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……..

26. Therapy rooms are made to feel welcoming and relaxing

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 take our time in getting to know our clients (typically assessment = 3 sessions) • 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

31. Our FORMULTIONS are all UNIQUE to the INDIVIDUAL CLIENT Individual Genes Biology Neurochemistry Neuroanatomy Attachment Social Opportunities Environment Socio-Economic Circumstances Culture & Religion Cognitive Style Personal Psychology Emotional Responsiveness Learned/Conditioned Behaviours +

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: • 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” • 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”

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

38. Training Outcomes

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 involvementwith our team

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 demonstratingthat 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!