DBT pilot Forth Valley: Trials and errors

1. DBT pilot Forth Valley:Trials and errors

2. Large georgraphical area; rural isolation; surprising socio economic deprivation in Alloa and Falkirk areaLarge georgraphical area; rural isolation; surprising socio economic deprivation in Alloa and Falkirk area

3. The beginning: something must be done Existing patients with BPD: time consuming, distressing No coherent approach BPD patients drift towards certain therapist Some therapists �don�t mind BPD� Liaison psychiatrist: 1000 DSH per yearLiaison psychiatrist: 1000 DSH per year

4. Numbers: in-patients 17th May 2005

5. Numbers: outpatients

6. Numbers: out-patients Forth Valley population 200.000 19-65 1%: 2000 no way!! Outpatient clinic: 10% 10 GA consultants: 20 BPD each, 10 �on the go� About 100 patients �on the go� Cornton Vale Prison (female) Cornton Vale Prison: a locked ward containing BPD patientsCornton Vale Prison: a locked ward containing BPD patients

7. The plan Use the staff who see BPD patients anyway Increase staffs� skill Funding: Choose Life Initiative Collect data: lots Don�t tell management Don�t think beyond the pilot

8. Would you like to receive training in DBT? 85 nurses shout: yes!! Selection by persistence

9. 1. Are you/ currently dealing with BPD patients? 2. How much time do you spent on such patients? 3. Can you/ your team afford to spend more time on such patients? Would you like to? 4. Do you have time for the training? 5. Will you have time for once weekly supervision? 6. Do you have a room to run group sessions in? Have you discussed your application with the local consultant psychiatrists/ service managers? How did they respond? Selecting therapists

10. Training days 6 therapists Chester 1st training week October 2005 Start treatment beginning Jan 2006 Once weekly group therapy (two groups) Once weekly team meeting Chester 2nd training week June 2006

11. Data collection Pre- programme: Staff and patient questionnaires Patient demographic information (incl. number of suicide and self harm attempts, medication use, admissions to hospital) Psychometric tests (GAS; HADS; DAST; SADD) During: Weekly patient session evaluations 8 weekly staff questionnaires/ evaluations Weekly therapist time logs Psychometric tests and demographic data to be collected after 6 months. Post programme: Staff and patient questionnaires Demographic data Psychometric tests Follow-up: Demographic data Psychometric tests.

12. Number games 16 patients (15 f, 1m) 3 patients have dropped out so far

13. Pre and during programme data

14. Patient feedback �There are other people the same as me� �they are teaching me to manage my problem� �It�s overwhelming�

15. Summary of Results low drop � out rate Less often suicide attempts Less alcohol, less time on psychiatric ward Depression and global functioning the same Most patients appreciative of intervention

16. Therapists� time per week

17. DBT: The problems It ain�t english time consuming: 3.5 hours therapist�s time per week per patient Hidden and open criticism from some colleagues Rocking the boat What happens when therapy stops For the uninitiated: Impenetrable jungle of american psychobabbles.For the uninitiated: Impenetrable jungle of american psychobabbles.

18. The delights Patients Good adherence They appreciate our efforts Remarkable improvement in a minority Therapists Sense of purpose and direction Cohesion

19. A sense of purpose and direction? Treatment for PD rather than avoiding patients vehicle for a service development � even if it isn�t DBT!

20. The active ingredients Validating environment A structure Being removed: �the specialists� Skills based: teaching patients to manage themselves Detaining patients, taking over control, close observations, making diagnosis are no issues A weird structure, but probably sound: a bit like houses: they can be weird, but if they have a roof and running water they�ll do. Wards, consultant psychiatrists, abusive fathers are all outside world. We don�t interfere with it directly. The principle is very different from the way such patients are dealt with usually (particularly by consultant psychiatrists who are forced kicking and screaming into �doing madness� with such patientsDetaining patients, taking over control, close observations, making diagnosis are no issues A weird structure, but probably sound: a bit like houses: they can be weird, but if they have a roof and running water they�ll do. Wards, consultant psychiatrists, abusive fathers are all outside world. We don�t interfere with it directly. The principle is very different from the way such patients are dealt with usually (particularly by consultant psychiatrists who are forced kicking and screaming into �doing madness� with such patients

21. How to do it better next time Involve management early Think of the time beyond the pilot Try two different models simultaneously Don�t underestimate the time Detaining patients, taking over control, close observations, making diagnosis are no issues A weird structure, but probably sound: a bit like houses: they can be weird, but if they have a roof and running water they�ll do. Wards, consultant psychiatrists, abusive fathers are all outside world. We don�t interfere with it directly. The principle is very different from the way such patients are dealt with usually (particularly by consultant psychiatrists who are forced kicking and screaming into �doing madness� with such patientsDetaining patients, taking over control, close observations, making diagnosis are no issues A weird structure, but probably sound: a bit like houses: they can be weird, but if they have a roof and running water they�ll do. Wards, consultant psychiatrists, abusive fathers are all outside world. We don�t interfere with it directly. The principle is very different from the way such patients are dealt with usually (particularly by consultant psychiatrists who are forced kicking and screaming into �doing madness� with such patients