“You have to start somewhere” – NSFT Strategy for Trauma-related Dissociation ESTD-UK Conference 31st March 2017

Helena Crockford

Consultant Clinical Psychologist

helena.crockford@nsft.nhs.uk

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….!