Putting the person back into personality disorder

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Putting the person back into personality disorder

• Improving services for people with Personality
  Disorder
• Dr Christine Leaman
• North Staffordshire Combined Healthcare NHS Trust
  

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Aims for todays 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?

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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

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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

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

• Small, traditional Trust
• CAMHS, Adult and Older Peoples Services
• Learning Disability Services
• Joint health and social care Trust
• Work with many partners in local health economy
• Local service users group North Staffs Users
  Group

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North Staffordshire Combined Healthcare NHS Trust

• Harplands Hospital
• Community beds at 4 (out of 5) local Resource
  Centres
• Adult services
• CMHTs
• In-patients
• Crisis Home Treatment
• Functional teams
• Used to have a therapeutic day service!

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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

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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

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The impetus for developing services
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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

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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

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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

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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

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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

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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

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Think personality!

• Putting the person back into personality disorder

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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)

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Core Team and Champion Model
Champion
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Core Team - membership

• Management team
• CAL
• Julie Elden
• Sue Imlack/Sheila Sheltie
• Heather Creasey

• Consultation team
• CAL
• Julie Elden
• Karen Mason
• Carl Woolliscroft
• Christina Fitzgerald
• Cat OCallaghan
• Graham Breeze independent supervisor

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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!

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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

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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)

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The Personality Disorder Service Putting the
Person back into
Personality Disorder
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The NSCHT PDS main functions

• Consultation to teams
• Service user involvement
• Education and awareness training

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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

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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

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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 everyones impressions and
  contributions are valuable

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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

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Consultation occurrences
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Numbers Present at Consultations
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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

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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

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Team Feedback Core Team
Was the Consultation Useful?
None 0/21
Some 6/21
Quite 12/21
Very 3/21
Core Team feedback
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Feedback Comparison
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Could the Core Team identify features of a
personality disorder in the patient?
Features of PD identified in patient (based on
Core Teams feedback) 17/19 Cluster A
1 Cluster B 14 Cluster C 3
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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

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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

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Core Team analysis

• Main problems brought by the MDT
• ? referral to therapeutic service or another team
  (eg rehab or assertive outreach)
• Issues re MDTs shared understanding and
  communication issues
• Unrealistic expectations eg re time-scale
• Feeling stuck and pessimistic re outcome
• Staff needing reassurance

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As discussed in Core Team supervision ...

• 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

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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

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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

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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

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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

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Treatment models the principles

• Accessibility
• Flexibility
• Consistency
• A coherent theoretical model
• Supervision
• Consultation
• Education

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Nice Guidance for Borderline Personality Disorder
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• Treatment management
• Issue date Jan 2009
• Developed by National Collaborating Centre for
  Mental Health

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The Personality Disorder Service Putting the
Person back into
Personality Disorder
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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

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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

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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

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The Champions

• 22 in 13 teams CMHTs, IP wards, CRT,
  functional teams, SW duty team
• All disciplines
• People who volunteer
• Have an interest in PD
• Want to learn more
• Want to develop skills

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The Service User Network

• Service user forum - aims
• To develop awareness of personality disorder
  locally among service users
• To inform re local services and opportunities for
  development
• To contribute to service development
• To contribute to planning and delivery of
  awareness training and education
• Potentially to become a supportive network

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Service User Network

• Run by service user network co-ordinator
• Monthly meetings in a non-NHS setting
• Wide publicity
• Agenda set each session
• Successful launch day in January 2009
• Developing a newsletter to go out in The Voice
• Contributing to Trust PPI days
• Participants in KUF training
• Quarterly carers meetings

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What else does the team do?

• Education and awareness training
• Education to MDTs, services and professional
  groups
• Training to partnership organisations
• Undergraduate and postgraduate teaching
• Professional groups
• Primary care
• All training opportunities are taken up
• All Core Team members contribute

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Training developments

• Champion training on-going
• Penetration to other teams
• Delivery of further training in NSCHT
• understanding causes of BPD
• attachment
• what works in teams
• Feeling shattered dealing with splitting
• Using supervision
• Trust training programme

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Knowledge Understanding Framework for PD

• DOH sponsored scheme
• Developed by a consortium
• Personality Disorder Institute (Pdi) at
  Nottingham University
• Tavistock Portman NHS Trust
• Borderline UK (part of Emergence CIC)
• Open University
• Training escalator from basic awareness to
  doctorate level training re personality disorder
• Awareness training e-learning supported by a
  virtual learning environment local training by
  teams

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West Midlands KUF

• Three PD Services won tenders to deliver
  Awareness level training
• Birmingham, Coventry and Warwick and NSCHT
• Personality Disorder Virtual Learning Awareness
  (VLA) Programme
• 6 e-learning modules
• Supported by 3 experiential workshop days
  jointly led by a professional and a service user
• Currently training to deliver in 2010-2011

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In summary

• Our aim remains to develop a therapeutic day
  service
• In the meantime we have a service which delivers
  parts of the Nice Guideline recommendations
• Education and awareness training
• It supports CMHTs in delivering Nice Guideline
• It supports the organisation in delivering Nice
  Guideline

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In summary

• We have put together an effective Core Team which
  is ready to develop a therapeutic service
• We have a service user forum which makes links
  locally and regionally
• We have increasingly well-trained staff who are
  able to champion personality disorder service
  user needs ...

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Think personality!

• Putting the person back into personality disorder