Transcript Meeting the needs of service users with Mental Health Problems

Meeting the needs of service users
with Mental Health Problems
Presentation by
Dr.S.Manoharan & Dr.A. Owen
(Associate Specialists)
on 13th January 2009
Topics to cover
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Defining & Contextualising clients’ needs
Health
Substance misuse and mental illness
What users and relatives want from M H Services
Active involvement of clients & carers
Treatment plan
Recovery
Happiness
What are the Challenges? What aren’t we meeting and Why?
Success stories
Pilot study-University of Wales
Dual diagnosis
National Service Framework (NSF) Sept 1999
Pilot study-University of Wales
Home Option Service (H.O.S)-Manchester Royal Infirmary (meeting
the needs of service users and carers?)
Intervention
Ways of defining clients needs
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In 1960’s, Sociological approach
In 1976, ‘rational planning’ and resource allocation based on
deprivation and epidemiology
In 1990’s, National Health Service reforms-need-target
resource allocation
In 1997, Jordon and Wright-In health care, need has a variety
of meanings which may change over time
In 2000, “collaborative action” where need for health care was
to be collectively identified by interested ‘stakeholders’
In 2002, Stevens et al. Interest in a needs-driven health system
pass through several stages
(Asadi-Lari et al)
Contextualising clients needs
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Societal view-Bradshaw defined as normative
Philosophical-instrumental or fundamental and
others highlights non-instrumental (or
absolute) sense of needs
Pragmatic view-Personal, societal and
environmental
Economists’ approach-cost confinement is the
focus of policy makers’ attention
(Source- Asadi-Lari et al. 2003)
Health
Definition:
“Health is a state of complete physical, mental and
social wellbeing and not merely the absence of
disease or infirmity”
Defined initially on the 7th April 1948
60 years later same definition is used.
However, it is very clear that definition cannot capture its
Complexity
(Source-Jadad A & O’Grady L. BMJ Group December 2008)
Substance misuse and mental illness
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Alcohol most commonly abused followed by cannabis and
cocaine.
Higher rates of use in male, young, less educated and single.
Substance abuse more common in those with better premorbid social functioning, Antisocial PD, F/H of substance use
disorders & or H/o trauma and PTSD
50% with severe mental illness have a lifetime substance use
disorder
25-35% with active substance abuse problems
Substance abuse associated with a wide range of negative
outcomes, including relapse and re-hospitalization, violence,
suicide, interpersonal problems legal percussions, health
consequences, and high treatment costs
(Mueser K T et al)
Why do patients take substances?
To self medicate?
 Coincidental?
 To belong to a social setting?
 Better an addict than mentally ill?
 Due to shared genetic links?
 All or some of the above
Other factors
 Genetic/biological vulnerability
 Environmental
 Sensation seeking traits
 Cognitive deficiency
 Poor coping styles
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Dual diagnosis
(Problems of mental disorder and substance misuse)
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Increased suicide
More severe mental health problems
Homelessness and unstable housing
Increased risk of being violent
Increased risk of victimisation
More contact with criminal justice system
Family problems
H/O childhood abuse
More likely to slip through the net of care
Less likely to be compliant with medication or other
treatment
(Banerjee et al)
What users and relatives want from Mental
health services?
Discussion
What users and relatives want from Mental health
services
Patients
 More info and involvement in decision making
 Good relationship with providers
 Clear management plans
 Good co-ordination among services
 Opportunity to record wishes in advance directives
 Contact with fellow clients
 Peer support
 Good communication with services
Relatives
 More supportive and intensive intervention
 Information
 Education about mental health issues
Clients/ Carers active involvement is crucial
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Psycho-education on substances
Motivation enhancement
Harm reduction / Reduction of suicidal ideation
Cessation
Maintaining cessation
Improving social skills
Replacement of meaningful activity with drug taking
rituals
Reducing clients isolation
Treatment plan
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Evaluating pressing needs
Determining clients motivation to change
Selecting behavioural goals for change based on both
functional analysis and clients motivational state
Determining intervention for achieving desired goals
Choosing measurable outcomes to and evaluate the effects of
intervention
Selecting F/U times to review implementation of treatment
plans and their success
Recovery- through peer support, socialisation, education
and training
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Self-esteem
Identity
Self-worth
Dreams
Pride
Dignity
Meaningful life
Dual Recovery anonymous
Happiness
Framingham Heart study (James H Fowler &
Nicholas A Christakis)
Longitudinal analysis-20 yrs
Ps 4739, from 1983-2003
Evaluated as to whether happiness can spread from
person to person and whether niches of happiness from
within social network,
Outcome: people’s happiness depends on the happiness of
others with whom they are connected. Provide further
Justification for seeing happiness, like health, as collective
phenomena
(Professionals & clients happiness)
What are the challenges?
What aren’t we meeting
and why?
(Discussion)
Some Challenges
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Resources
Setting welcoming
Flexibility
Creativity
Availability
Approachability
Beyond symptoms
Prevent crisis
Dealing with crisis
Professionals who know what they are doing (lack of training)
Professionals willing to learn
Professionals proactive rather than reactive
Success story
Client 1: F-40, divorced-10yrs, Boyfriend-7yrs (In prison
4yrs), 2 sons ( youngest lives with his grandparents)
Father-depressed for several yrs, Parents separated
First session -looked angry, c/o feeling depressed, suffer
from social phobia and remain in doors mostly, alcohol
dependency, sisters anniversary in few wks, unable to
cope, felt suicidal and started drinking heavily. Sister was
murdered 6 yrs ago. Father was blaming her for her sisters
death as they both used to take drugs together in the past.
Smoked cannabis 1-2 joints once in every 2-3 wks
P/H several deaths (friends and relatives), never had bereavement counselling.
Had used several drugs.
Care plan
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Community alcohol detoxification-successful. Relapsed once
after her uncles’ funeral
Bereavement counselling (by key worker)
Seen by trainee Psychologist
Psychotherapist at Munro centre
Complementary therapies at CDAT
1:1 session with key worker-motivational interviewing
Attended Red-kite-after persuasion
Completed training to become an advocate
Currently attending various courses and doing voluntary work
with service users
Client is pleased about the progress and the team too is pleased
about the outcome
Success story
Client 2:
F-32, separated from her husband (2 daughters),
frequent self-harm (cutting her arms and or O/D),
feeling depressed and suicidal, alcohol dependency
Requested help for depression and alcohol dependency.
P/H In-patient detoxification
Relapsed within few wks.
Not keen to go for in-pt treatment again
Care plan
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Equinox-contacted me 2 days before completion-with persuasion
stayed and completed
Went into rehab -3m , another 3 months arranged by the S.W. Left a
message for me to contact. Wanted to leave prematurely. Left her to
decide as to whether she wanted to stay or leave.
Left the rehab and came back for 1:1 session
Discussed about the possible discharge in the near future.
Consultant requested a favour ie not to discharge her yet as one of us
is the mother to her and other person is the agony aunty. The client
had not presented with self harm for quite sometime.
1:1 session continued
Finally discharged
Recently spoke to the client and she thanked me again for all the
support that I gave her.
National Service Framework (NSF)- Sep 1999
Aims: 1. Improve service provided
2. To challenge the population myths surrounding
mental illness
Expectation of service users
 Involve users/ carers in planning & delivery of care
 Be suited, accessible and non-discriminatory
 Safety of the service users, carers and the public
 Offer choices
 Be well co-ordinated between staff & agencies
 Empower & support staff
 Be accountable to public, service users and carers
Pilot study-at university of Wales
(March 2002-2005)
Findings and recommendations:
 Adequate funding for mental health service user involvement
 Meaningful service user involvement
 Outreach work and non-threatening methods of engaging
 On-going support to service user representative
 Joint training to facilitate good working relationship and user
involvement
 Identify and maintain good relationship with senior managers
 On-going training and support
Home option service
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(Manchester Royal Infirmary)
Medical management
Support
Safe & quiet environment where users able to support each
other
O.T
Psychosocial intervention
Drug/ alcohol intervention
Specific psychosexual/ couple therapy
Stress management
Creative activities- Improve self-esteem, confidence &
concentration
Advice regarding accommodation, bills etc
CPA
How meeting the needs of service users?
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By developing care plans that meet the client needs
By respecting choices made by clients regarding where &
when the team should visit them
Respecting confidentiality
Information about treatment options & side effects
Identify & involve service users at steering group level
Evaluating users perspective by evaluation questionnaire &
interviews on discharge from the service
Interpreter service & also to liaise closely with ‘Link Worker
Scheme’ within the Trust to ensure we are operating towards a
culturally sensitive service, providing translation and assisting
in the clarification of cultural issues.
How meeting the needs of carers?
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Full assessment of carer needs during the admission to H.O.S
Involving carers in assessment & asking about their
experiences of clients distressing symptoms & experiences
Providing carers with emergency telephone numbers
Aware of key workers & ensuring staff are available to speak
to the carers
Aware of early warning signs & how to seek assistance
Information of the local & national carers groups &
organisation
In some cases specific carers / Family intervention might be
offered
Interventions
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Educational training sessions
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Coping strategy enhancement
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Problem solving
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Stress management
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Developing good communication patterns and goals with
clients during their illness
Reading list
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Harbottle K. The problem is not the drug –Community care 713 April 2005
Mueser K T et al. Integrated treatment for Dual disorders, a
guide to effective practice
Gerada C. ‘RCGP Guide to The Management of Substance
Misuse in Primary Care’
Blenkiron P & Hammill C A. What determines patients’
satisfaction with their mental health care and quality of life.
Post grad. Med.J 2003;79;337-340
Watts M. High expressed emotion, severe mental illness and
substance use disorder. British Journal of Nursing,2007,Vol
16, No 20
Asadi-Lari et al. Health and Quality of Life Outcomes
(Available from Http://www.hqio.com/content/1/1/34)
Jadad A & O’Grady L. BMJ Group December 2008
D.O.H publication on ‘Dual diagnosis good practice guide’