Transcript Document

Afternoon programme
13:30
Mentalisation: its role in reducing the need for
restrictive interventions
Dr Damian Gamble, Consultant Forensic Psychiatrist,
Llanarth Court
14:00
Positive and Proactive Care in Practice: A case study
from high secure services
Dr Polly Turner, Forensic Psychologist and Chris Stewart,
Ward Manager, Ashworth Hospital
14:40
Nurturing and Developing Mental Health Student
Nurses at Cardiff University
Elizabeth Bowring-Lossock, Lecturer, Mental Health
Nursing, Cardiff University
15:15
Final questions
15:30
Close
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Mentalisation: its role in reducing the
need for restrictive interventions
Dr Damian Gamble
Consultant Forensic Psychiatrist
Llanarth Court Hospital
Working with personality disorder: problems
Staff feeling relatively unskilled in dealing with patients with
personality disorder
Lack of training and experience
No theoretical model or a number of theoretical models can be
confusing
Lack of knowledge of what works – therapeutic pessimism
Therapy for personality disorder seen as a specialist intervention
carried out by highly skilled practitioners
Use of restrictive interventions seen as the only way to deal
with risky behaviours
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
3
Searching for solutions
Need for a consistent theoretical approach that is understood
by all staff
Practical knowledge and skills than can be acquired and used
relatively quickly
No “dumbing down” of theory or practice
Inclusivity – all patients and staff must understand the model
Essential that any intervention is evidence based
Published research
Collection of outcome measures
Ensure team remain “on model”
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
4
Mentalisation – what is it?
Linked to attachment theory – existing body of knowledge
The capacity to reflect on one’s own mental state and the
mental states of others
Explicit focus on mind not behaviour
A capacity everyone has but can’t always use
Can be impaired by emotional stress, tiredness, agitation
Impaired in patients with various mental disorders, including
personality disorder
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
5
Mentalisation and personality disorder
Patients with emotionally unstable (borderline) and dissocial
(antisocial) personality disorder have problems with emotional
dysregulation
High levels of emotional arousal impair the capacity to
mentalise
When mentalisation breaks down there is a “switch” to nonmentalising styles of thinking leading to:
Concrete, inflexible thinking
Generalisations and assumptions
Paranoia
Psychotic experiences
Violence and self-harm
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
6
How mentalisation based treatment works
Mentalisation based treatment aims to develop the patient’s
capacity to mentalise by various techniques including:
Teaching the therapeutic model
Active therapeutic engagement
Modelling a curious “not knowing” therapeutic stance
Demonstrating empathy and “coming alongside” the patient to
reduce emotional arousal and paranoia
Focus on internal mental processes rather than external factors
and behaviours
Promoting flexible thinking by offering alternative perspectives
Encouraging discussion of feelings regarding the therapeutic
process and relationship
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
7
Training of staff in MBT model
Important that all staff understand the model to ensure a
consistent therapeutic approach
Nursing team to have a central role
External MBT training of a multidisciplinary MBT team:
2 Charge Nurses
1 Deputy Charge Nurse
1 Staff Nurse
2 Psychiatrists (1 Consultant, 1 Associate Specialist)
1 Psychologist
Regular internal training of all ward staff delivered by MBT
team
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
8
MBT supervision structure
Supervision for staff working with personality disorder is
essential and stipulated in NICE guidelines
External supervision for MBT team from senior clinician in a
well-established MBT service (London)
Internal peer supervision for MBT team
Internal supervision of staff through weekly ward-based
reflective practice
In addition to usual hospital clinical and managerial
supervision
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
9
Creating a “mentalising culture”
Twice weekly ward community meetings
Attended by all patients and all ward staff and MDT
Patient-led meeting
Patients are encouraged to discuss current issues with support
from staff
Patients helped to find their own solutions to any problems
Mentalising used in ICRs, CTP and CPA meetings (where
appropriate)
Staff encouraged to use mentalising techniques in routine
clinical encounters
Importance of building confidence for all staff to use MBT
techniques
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
10
Iddon ward MBT programme
In addition to developing a mentalising ward culture, Iddon
offers a full MBT programme for patients with personality
disorder according to established treatment model
Evidence-based treatment for personality disorder
12-week psychoeducation module
Weekly 75 minute group
Weekly 45 minute individual session
Therapy delivered by MBT team
Significant hospital investment in terms of treatment,
supervision and training
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
11
Reducing restrictive interventions (1)
Aggressive / violent incidents arise from a breakdown in
mentalising
Emotional arousal leads to pre-mentalising thinking such as
paranoia, rigidity, emphasis on action vs thinking
While in this state of mind patients are more likely to respond
with violence
While in this state of mind patients are not able to reflect or
see another perspective
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
12
Reducing restrictive interventions (2)
“Therapeutic authority” – knowing the therapeutic direction but
not assuming you know “why”
“Stop and stand” means holding onto importance of thought
Mentalisation is a process not an outcome
Immediate risk behaviours are not ignored but are dealt with
using a collaborative approach
By focussing on patient’s mental state rather than behaviour,
he / she feels understood
By “coming alongside” the patient, nurse / therapist is no
longer perceived as a threat – may reduce risk
This approach does not “condone” or minimise risk behaviour
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
13
Reducing restrictive interventions (3)
“De-escalation” of the situation results from patient regaining
capacity to mentalise
By definition, mentalisation involves patient being able to
reflect, see other perspectives, flexible, not paranoid
A patient who is able to mentalise no longer feels the need to
act aggressively
Mentalisation is an ability to be learned over time
Mentalisation is a thinking process, not an outcome
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
14
Does it work? Ward level changes
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
15
Does it work? MBT programme
Patients in MBT programme report fewer symptoms
Self-Report Psychiatric Symptoms (SCL-90)
1.6
1.4
1.2
1
0.8
SCLGSI
0.6
0.4
0.2
0
PreMBT
3 Months
6 Months
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
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MBT programme results
Patients in MBT programme report improved wellbeing
Self-Report Wellbeing (WEMWBS)
60
50
40
30
WEMWBSTot
20
10
0
PreMBT
3 Months
6 Months
Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
17
Positive and
Proactive care
A case study from high secure services
CHRIS STEWART | POLLY TURNER
On behalf of Positive and Proactive Implementation
Group
Overview
• Background to HSS
• Management of patients with chronic and serious violence
• Positive Intervention Programme (PIPs)
• Case study
• Application of positive and proactive care in HSS
• Future directions
Current Context
• Positive and Proactive Care:
Reducing the need for
restrictive interventions (DoH,
2014)
• In
response
to
reports
outlining the use or abuse of
restrictive practice in health
and care services
• To offer “a framework to
support the development of
service cultures and ways of
delivering care and support
which better meet people’s
needs and which enhance
quality of life”
• A Positive and Proactive
Workforce (DoH, 2014)
• To minimise the use of
restrictive practice in social
care and health
• To develop a workforce
that
is
skilled,
knowledgeable, competent
and well supported to work
in a proactive and positive
way
Issues in High Secure Services
• Small group of patients in High Secure Services who are
chronically challenging and demonstrate the propensity
for extreme violence
• Definition of Seclusion: Code of Practice (2008; 2015) “the
supervised confinement of a patient in a room, which may be
locked to protect others from significant harm. Its sole aim is to
contain severely disturbed behaviour which is likely to cause harm
to others.”
• Long Term Segregation: Code of Practice (2015) “…substantial
risk of harm posed by the patient to others, which is a constant
feature of their presentation … the risk of harm to others would not
be ameliorated by a short period of seclusion combined with any
other form of treatment”
• Seclusion can have a substantial impact upon both
patients and staff causing emotional and psychological
effects (Moran et al., 2009)
Effects of
segregation
• Social anxiety, impulsive behaviour,
powerlessness (Haney, 2006)
• Maintenance of hallucinations, persecutory
beliefs (Garassian & Friedman, 1986)
• Aggression-coercion cycles (Patterson &
Forgatch, 1985)
• Reduced opportunity for engagement in physical
activity leading to poor physical health and
obesity (Wirshing, 2004)
Positive Intervention Programme
• Integrated specialised team that supports patients and the
clinical teams in the management of long term segregation
• The PIP Service uses recovery based principles to provide
patients with positive relationships and meaningful activities to
improve their mental health and quality of life
• The PIP team enables the service to address the physical
health needs of patients in long term segregation
• The PIP Service promotes positive culture change utilising
principles from Trauma Informed Care and Progress Enhancing
Strategies
• The overall aim is to promote inclusion and positive
participation and ultimately to support the patient and the
clinical team to enable them to make the changes necessary to
end the segregation
Aims of PIPs team
• To intervene at a systems level
⁻ Modelling work with secluded patients to shift &
challenge perceptions of risk
⁻ Training to improve skills in managing violence &
aggression
• To intervene at an individual level
⁻ Restore hope
⁻ Increase engagement in therapeutic interventions
⁻ To lessen the potential negative effects of seclusion
⁻ Provide purposeful, meaningful activity
⁻ To promote social skills & social boundaries
⁻ Improve quality of life
Progress enhancing
strategies
Graded
Exposure
& Activity
Clear Goals
&
Plans
Individualised
Treatment
Strategies
Physical &
Environmental
Management
Progress
Enhancing
Strategies
Relationships
&
Connections
System
Management
Training
Leadership
&
Culture
Case study: Background
• 34 year old Male
• Diagnosis of Paranoid Schizophrenia (pre-dates 1996)
• Admitted to Ashworth 15/12/2000 after conviction of
Robbery and Burglary
– Section 37/41 MHA 1983
•
•
•
•
•
•
Family history of mental illness
Limited educational achievement
Erratic employment history
“Keen boxer”
Poly-substance abuse (crack cocaine, LSD, cannabis)
Significant acquisitive & violent offending
Patient ‘A’ - Life in
Ashworth
• Almost 11 years in segregation as a result of
serious assaults on nursing staff & peers
• Periods of association agreed when commenced
Clozapine, became non-compliant and resecluded without incident
• Rebound psychosis & refusal to take medication
• Enforced depot medication given with assistance
of MVA response team
Patient ‘A’ presentation
Severe social skills deficits and
anti-social & narcissistic
personality traits
Continued psychotic symptoms,
command hallucinations,
thought disorder and high levels
of paranoia
Clinical
Presentation
Guarded, unpredictable, easily
aroused, poor impulse control,
few protective risk factors
Highly distrusting of all clinical
staff and suspicious of all
attempts at therapeutic
engagement
Positive Intervention
Programme
• In July 2009 the intervention began
• PIP working jointly with Psychology
• Delivered a treatment programme that included
motivational sessions to take Clozapine & engage in
a structured goal oriented re-socialisation plan
• Family involvement throughout
• Resulted in:
– Decrease in symptomatology
– Reduced incidents
– Engagement with Psychology (mental health education,
skill building, Mindfulness)
Incident data since 2009
Progress over time
• At times, staff beliefs and perceptions of risk became more
prominent - as association increased so did anxiety
• Unfortunately these beliefs were reinforced after a violent
incident
• Moved wards (x2) and the plan returned to the first stage of the
re-association plan
• Unlike past incidents and disruptions to progress resulted in
non-compliance with medication & rebound psychosis –
continued to comply with all aspects of treatment
• Considered that residual difficulties relate more to underlying
personality disorder
• Long term treatment needs continue to be addressed which
include:
–
–
–
–
–
To treat Paranoid Schizophrenia & Antisocial personality disorder
To develop self-esteem & improve sense of identity
To increase interpersonal effectiveness
Build further skills in emotion regulation & mindfulness
To decrease the effects of institutionalisation & increase socialisation
Current ward & PIPs
interventions
• Graded exposure & activity
• System management
• Training
• Clear plans and goals
• Relationships and connections (e.g. family)
• PBS plan …
The Risk Behaviour Describe the challenging behaviour that can lead to the use of more restrictive practice, use clear,
measurable terms (e.g. What, When, Where, How, Whom)
Violence- Threats of violence & physical violence during periods of activity (pre and post), and via hatch when interacting with
staff
May punch, kick, spit, grab clothes, head butt; most likely to target staff due to restrictions currently
What are the TRIGGERS of RISK behaviours? (Think
about using available risk assessment information e.g.
START)
What can be done to REDUCE impact of TRIGGERS (e.g.
any protective factors already identified?)
Paranoia (believing something bad is imminent, going
to be taken away, people have tampered with food,
belongings)
Social support (e.g. contact with family), increased activity, medication
(PRN and prescribed), encourage communication with staff and
explore coping, offer positive reassurance using established
relationships, future focus,
Structure env. (quiet, time limited), positive & consistent interactions
Non compliance with medication, feeling aggrieved at
others, perception of lack of control, perception of lack
of hope, feeling bullied
What do the team believe the patient should do instead (the
alternative should meet the need of the patient)
What is believed to be the function of the behaviour
(why does the team believe the behaviour occurs- what is
the function)
Wants retribution against those he feels aggrieved against
To reduce feelings of anxiety, to feel safe, to regain
control
Engage and co-produce care plans (increase control)
Explore new ideas through engagement in meaningful activity
Talk – tell his story, express his thoughts and feelings, self report
changes
Engage in problem solving to select ways to cope and develop
Accept support from others
Take prescribed medication
What happens when risk escalates for this individual?
Feelings
Fear, anxiety, anger
Thoughts
Physical Sensation
Something bad is going to
happen, You deserve to be
punished
Feels sick, stomach turning,
“fuzzy head”
If presented with the challenging behaviour, it
maybe helpful to try the following interventions
(specify how staff should respond in short and long
term to de-escalate/reduce the degree of the
challenging behaviour.
Short Term
Keep calm (speech rate/volume)
Offer reassurance
Offer PRN medication
Promote hope, be positive
Change the environment – offer an alternative area, use
distance to clear route to room
Explore using solution focused approaches
Engage with person has a good relationship with
Behaviours
Threats, hyper vigilant
Physical violence
In What Situations is the
behaviour most likely to occur?
Following / before stressful events
(meetings, visits, family loss)
Feeling others are forcing him into
things
Over stimulation , feeling aggrieved /
let down
What are the consequences when
the behaviour happens that makes
it likely to happen again?
Withdrawn from env. Removed from
anxious situation/trigger, return to
segregation, supports ideas of persecution
If an untoward INCIDENT occurs as a
result of the behaviour how is it best
dealt with?
Give reassurance,
Redirect to positive thoughts about progress
Use people with positive relationship to talk
Use distance – give space (Give clear route to
own space)
PBS in practice in HSS:
Future directions
• Accessible information for all levels of staff
• PBS plan
• Collaborative process with the patient
• Responsibility for MDT to create, review, update
• To pilot the PBS plan across High dependency
and medium dependency wards
Contact details
Mr Chris Stewart
Ward Manager, HSS
[email protected]
Dr Polly Turner (CPsychol)
Forensic Psychologist
[email protected]
Positive and Proactive:
Nurturing and Developing Mental Health
Student Nurses at Cardiff University
Elizabeth Bowring-Lossock
Mental Health Admissions Tutor
School of Healthcare Sciences
Cardiff University
Use of restrictive interventions:
• Long history of restraint – mechanical, physical (inc
seclusion), medicinal
• Some unreasonable and some reasonable reasons
• Undesirable and unwelcome outcomes
• Just because (key swingers)
What are we looking for:
• From the beginning…….
• Mini Multiple Interviews
• Knowledge, Skills, Attitudes
• Assessed throughout in order to progress
Mental Health Nursing Practice is a
complex discipline in a complicated
world
• Vulnerable, stigmatised client group
• Professional and legal obligations
• Ethical expectations
• Codes, guidance, quality assurance
Positive and proactive:
•
•
•
•
•
Thinking and communicating
Problem solving – focussed
Compromise
Creativity and Assertion
Resolution?
• Built on strong foundations – individual, holistic
• Accountability to self – why am I doing what I am? Why
am I doing this?
• Obligation to seek self care
Violence and Aggression All
Wales Passport, Welsh
Government
• Guidance sets out to build foundations
• Passport approach – currently being updated
Student experience:
• Forensic settings including Llanarth Court Hospital
• Opportunities for students to experience working in
secure environment with expert nursing staff
• Once qualified, students often come from CU for
first Staff Nurse position here – we must all be
doing something right.
• Facilitating the development of mental health
nurses who need to make decisions based on best
evidence, professionals codes, legal and other
guidance and their best judgement in a complex
clinical environment
• Positive and Proactive
Questions from the audience
& close of conference
45