“You have to start somewhere” - ESTD Training …€œYou have to start somewhere” ... ESTD-UK...
Transcript of “You have to start somewhere” - ESTD Training …€œYou have to start somewhere” ... ESTD-UK...
“You have to start somewhere” – NSFT Strategy for Trauma-related Dissociation ESTD-UK Conference 31st March 2017
Helena Crockford
Consultant Clinical Psychologist
Background – Drivers From Literature • Prevalence data (1%-3%, e.g. Johnson et al, 2006)
• Delayed diagnosis and mis-diagnosis
• Iatrogenic effects
• Inappropriate and expensive treatments (i/p
admissions, anti-psychotic meds etc)) (e.g Ross and
Norton, 1988)
• Evidence on cost-effectiveness (Lloyd, 2011)
• Emerging consensus on best practice (ISSTD, 2011)
Background – Local Drivers
• Financial pressures - Trust wanting to reduce external
placements
• Complaints - SUs’ relationship breakdown with Trust/statutory services
• Complex cases in teams - team working problematic
• Psychological therapy staff felt isolated with cases, or
floundering
• General lack of knowledge and awareness amongst
mental health staff and supervisors
Strategy Development
• Norfolk Senior Psychology Group
• Agreed to identify senior psychological practitioner
within each locality to develop clinical leadership in
dissociation and serve as local resource
• 4-day therapist level training (ESTD-UK / FPP)
• Formed working group
• Produced annual strategy
• Not envisaged as a specialist service model –
improving services which were already available
Aims of strategy
• Improve time to accurate diagnosis and identification
• Improve service user outcomes
– Demystify and change attitudes in mental health workforce
– Develop skills - therapist and generic mental health skills
– Leading to more appropriate mental health care
• Reduce the risk of iatrogenic interventions
– Can arise through lack of understanding or awareness.
• Improve cost-effectiveness
– Timely implementation of appropriate interventions
– Reduction in expensive but inappropriate treatments which may result from misdiagnosis.
First Steps Strategy set out the following:
1) Undertake baseline audit.
2) Improve skills/awareness of multi-disciplinary mental
health staff.
3) Improve therapist-level skills.
4) Identify appropriate interventions
– realistic within existing services.
5) Consider areas of unmet need
– processes suitable to address these.
1) Needs Assessment
Baseline audit of MDTs
• Questionnaire given to team members at team meeting
• Asking about: – Dissociative cases on caseloads
– Knowledge, skill and confidence working with Dissociation
Needs Assessment - Results
Team N % of DD
clients on
overall
caseload
(Mean)
Rating of
knowledge
of DD
(0-10)
(Mean)
Rating of
confidence
to identify
DD (0-10)
(Mean)
Rating of skills
to support
clients with DD
(0-10) (Mean)
Coastal
Youth
6
9.3%
4.6
5.4
3.6
Adult
Central
11
4.2%
4.1
4.5
3.3
2) Awareness-level Training
– Open to all MDT staff
– Co-produced and delivered with expert-by-
experience
– Aims:
• Increase basic knowledge and core skills.
• Demystify and improve attitudes
• Improve earlier identification and reduce misdiagnosis.
• Improve staff confidence
• Improve quality of care
• Reduce iatrogenic interventions
Awareness-level Training
– What is Dissociation?
– Development and Neurobiology
– Living with Dissociation
– Stabilisation and Support
Awareness-level Training – Year 1 Pilot
• Evaluation
• Lots of interest - Course booked up quickly
• Range of professionals attended (psychol/ medic/
CPNs/ Support workers etc.)
• Attitudes were open, engaged, brought case
examples.
• Feedback:
– “I was able to relate the course content to my job” (1 –
strongly disagree to 4 – strongly agree): Mean rating = 3.6
– 23/23 respondents said “YES” the course was worthwhile in terms of time away from other work commitments
– “I would recommend this course to my colleagues” (1 –
strongly disagree to 4 – strongly agree): Mean rating: 3.8
Awareness Training – Year 2
• Training Dept. agreed to some backfill for trainers’ time including expert-by-experience
• 3 dates booked out very quickly - w/l formed
• Further dates requested during year from particular
groups (medics, IAPT)
Awareness Training - Evaluation • N = 100 + attended
• Full range of mental health professionals
• From across full range of service lines
• High average ratings on usefulness and relevance
• Example comments: “(Expert-by-experience) being part of the training team is invaluable.” “Inspiring reminder of the values necessary to underpin our work” “Extend course to 2 days, to allow more time for training on strategies and therapy skills.”
3) Therapist Skill Development – Year 1
• Cascade model
• Area leads attended 4-day foundation training (ESTD-
UK / FPP)
• Took on dissociative cases from within own clinical
area
• Formed monthly supervision group with expert
facilitator.
• Area leads offered consultation and supervision to
other practitioners within their locality.
Therapist Skill Development – Year 2
• Leads continued with monthly supervision group -
developing skills takes time.
• Ensuring 1-2 dissociative clients on caseload
• Supervision and consultation cascade work continued
• 4-day ESTD-UK Post-foundation training (1 of us)
• Encouraging more therapists to uptake therapist level
training
Skill Cascade Activity Data
Number
of cases
Hours -
approx
Type of activity Service involved
Supervision
of psych
therapy
colleagues
16 32.5 -Within regular supervision
-Supervision for one-off
cases
-Adult service line
-Youth
-Wellbeing (IAPT)
-RAF
Consultation
to MDT
colleagues
22 26.75 -1:1 discussion
-Phone consultation
-Team Meeting
-Joint assessment
-File review
-CPA review
-Ward round
-Support with funding panel
application
-Adult service line
-Youth
-Medium Secure
-In-patient
-Wellbeing (IAPT)
4) Co-production – Focus Group for Service Users and Carers
HAVE YOUR VOICE HEARD!!
If you have lived experience of
Dissociative Difficulties,
either yourself, or someone close to you
COME AND HELP US PLAN THE WAY FORWARD
• You can attend the focus group in person.
• You can give us your views 1:1 over the telephone.
• You can send us your comments and suggestions
in writing.
Focus Group • 13 Contributors to first event
• in person (4 x SUs, 2 x Carers)
• by phone (2 x SUs)
• in writing (4 x SUs)
• Thematic analysis of content – 7 themes identified
1. Responses to service user involvement
2. What hasn’t worked
3. Improved knowledge and understanding
4. Accurate assessment and identification
5. Continuity of care
6. Better communication
7. Appropriate Treatment
Focus Group - themes
WHAT HASN’T WORKED
BEING LEFT WITH
NEGATIVE FEELINGS BARRIERS TO ACCESSING
CARE
EXPERIENCES OF
DISRESPECT
INAPPROPRIATE
CARE
LOSS OF CONFIDENCE IN
THE SYSTEM
HELP OUTSIDE NHS IS
BETTER BUT EXPENSIVE
Focus Group - themes
IMPROVED
KNOWLEDGE AND
UNDERSTANDING
ACKNOWLEDGE
AND FOSTER
STRENGTHS –
ALONGSIDE
VULNERABILITY
OF OTHER
PARTS
NOT FEELING PUNISHED
FOR HAVING DISSOCIATION
MORE GENERAL
AWARENESS AND
UNDERSTANDING
eg. GPs, A&E
MORE AWARENESS AND
UNDERSTANDING IN
MENTAL HEALTH CRISIS
PATHWAY - IN-PATIENT,
LIAISON STAFF, CRHT ATTITUDE CHANGE
-OPEN
-ACCEPTING
-VALIDATING
PSYCHOEDUCATION
MORE SPECIALIST
UNDERSTANDING
AMONGST
PROFESSIONALS
FOR CARERS
Focus Group - themes
BETTER
COMMUNICATION
OPENNESS AND
TRANSPARENCY
BETWEEN
PROFESSIONAL
AND SERVICE
USER
JOINED UP CARE –
COMMUNICATION
BETWEEN
PROFESSIONALS
MANAGING
THERAPEUTIC
RUPTURES
CONSIDER
COMMUNICATION
WITH AND
BETWEEN
DIFFERENT PARTS
MAKE INFORMATION MORE EASILY
AVAILABLE E.G. HEALTH PASSPORT
COMMUNICATION
WITH CARERS
CONSIDER
COMMUNICATION STYLE,
AS MUCH AS CONTENT
Focus Group - themes
ACCURATE
ASSESSMENT AND
DIAGNOSIS
USE OF
APPROPRIATE
SCREENING AND
ASSESSMENT
TOOLS
FEWER
ASSESSMENTS
EARLIER IDENTIFICATION
5) Identify Appropriate Interventions a. Assessment and accurate identification b. Individual psychobiosocial formulation
c. Psychoeducation and information (service users and carers)
d. Stabilisation of the network of support - care plan, crisis plan
e. Developing psychological self-management skills, improving general wellbeing and quality of life goals
f. Psychological therapy - focused and time-limited
g. Psychological therapy – extended (allowing time for a secure attachment relationship and trauma work)
h. External provider (for highly complex presentations, where the relationship with statutory services has broken down).
i. All supported by appropriate clinical supervision.
6) Reflections and Challenges
• Surprised by how valued and welcomed this was
• There were things we could do, and ways we could highlight needs which were harder to meet.
• Really important to be in a group
• Sustaining the lead role coverage
• Only taken up by 1 county in trust, not the other.
• Building therapist skills – linking with local training plans/ staff appraisals
• Psychiatry involvement
• Link strategy in to wider trust strategy streams
Next steps…
• Co-production, further focus group to develop aims.
• Recovery college course for psychoeducation for service-users, carers and staff?
• Further training day with more emphasis on intervention skills?
• Linking strategy into wider trust strategy
• Trial longer-term interventions – Single case research to evaluate cost-effectiveness? Approach to commissioners?
“We have to start somewhere…”
1) What do you want to change and why?
2) What relevant drivers are there in your Trust?
3) What existing strategy could you link into?
4) Who might be your allies?
5) Where are your opportunities for influence?
6) What are your possible first steps? Be hopeful, but
realistic….!