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Psychosocial Psychiatry and Assertive Outreach David Dodwell Consultant Psychiatrist Peterborough & North Cambs Assertive Outreach Team Cambridgeshire & Peterborough NHS Foundation Trust Outline - 1 • • • • • • Acute versus chronic Complexity Psychosocial Interventions (PSI) Strengths & recovery Change Therapeutic relationships Acute versus Chronic ACUTE - appendicitis RECURRENT - episode - relapse prevention CHRONIC ACUTE-ON-CHRONIC PROGRESSIVE RISK - external - internal - cigarettes cholesterol, moderate HT ACUTE CHRONIC staff training good weak staff-pt paternalistic collaborative pt involvement passive active/expert outcome quick minimal/absent complexity low high concurrent issues few/irrelevant common & pertinent ethics black & white grey (e.g. 999 for chest pain) A stepped care approach to chronic disease Level 3: Highly complex patients Case management Level 2: High risk patients Care Management Level 1: 70-80% of a Chronic Care Informed self-management Health promotion From Dept of Health (2004, p. 4) MULTIPLE DISORDERS - Types • Other ‘axis I’ – depression, anxiety • Substance abuse • ‘personality’ issues • physical comorbidity • social factors - inactivity - poverty - isolation / loneliness / alienation - hostility / victimisation Theory – ‘multiaxial’ classification (a) DSM IV I. II. II. clinical disorders other potential focus of clinical attention personality disorder mental retardation III. general medical conditions IV. psychosocial and environmental factors V. global assessment of functioning Theory – ‘multiaxial’ classification (b) ICD-10 – childhood I. II. clinical psychiatric syndrome specific disorders of psychological development III. intellectual level IV. medical conditions V. associated abnormal psychosocial situations VI. global assessment of disability Theory – ‘multiaxial’ classfication (c) ICD-10 – adulthood I. II. III. IV. clinical diagnoses disabilities contextual factors (includes Z codes) WHO 1980 – Impairment, disability, handicap aetiology pathology manifestation of disease impairment disability handicap Impairment - abnormality of structure / function (organ) Disability - difficulty in performance / activity (person) Handicap - disadvantage to individual (social) Disorder Symptoms & signs Impairment Disability Handicap schizophrenia hallucinations volition personal hygiene social integration communication talking occupation attention listening economic selfsufficiency structure tasks family work benefits antipsychotics head phones support activity support social contact WHO 2001 functioning, disability, & health • Body function • Body structure • Activities & participation • Environmental factors Models of disorder group of symptoms/signs + course disability activity group of symptoms/signs ‘disorder’ impairment context structure/function symptom/sign handicap participation pathology Cause based on Wulff (1976); World Health Organisation (1980, 2001) context = environmental and personality factors which mutually interact Die Diagnose ist das Unwesentlichste Formulation Biological Psychological Social [values] Predisposing Precipitating Perpetuating [protective] Interventions Whomsley, 2009 What are psychological interventions? • Education/information - patient - carers • Family work (EE reduction) • Medication management • CBT for psychosis (depression, anxiety) • Specific techniques (solution-focused; cognitive remediation) • Creative therapies (Cochrane, not NICE) • Relationship management (patient-staff) & support What is a social intervention? • • • • • • • Welfare benefits In-patient/admission Supported accommodation Befriending Social opportunities Activities (often social) Indirect - working with carers - liaising with other agencies • Addressing abuse • Conform to spiritual/cultural issues Are social factors important? International Study of Schizophrenia (ISoS) Outcome favourable developing:developed odds ratios 1.6 to 3.5 Best outcome rural Chandrigarh (not psychotic last 2 years) Death rate (SMR) worse in industrialised countries Social factors (2) • Warner (2004) • Tikopia (Firth, 1961) Strengths Rapp & Goscha 60’ of “why your life is shit” is depressing Doctors rarely discuss strengths/assets Medicalisation versus normalisation ‘RECOVERY’ Not ‘restitutio ad integrum’ Personal journey & adaptation • • • • • • identity autonomy / control rôle meaning hope connectedness Includes psychosis? Wellness Recovery Action Plan • • • • • Daily maintenance Triggers (and action) Early warning signs (and action) Breaking down (and action) Crisis plan/advance directive Copeland Sequence and timing • Vicious cycle virtuous circle • Weakest point • Most accessible point • Opportunity Cycle of change •Precontemplation •Contemplation •Preparation •Action •Maintenance •Recycling (relapse and learning) •Termination Prochaska et al. Phases of intervention • Engagement - often practical assistance - loss leader • Intervention • Maintenance • [step down / discharge] Therapeutic relationships “Effective care for the severely mentally ill needs to be embedded in a supportive and trusting relationship” Burns + Firn (2002) Maximise ‘placebo’ effect Drama triangle Persecutor Rescuer Victim Bystander Karpman; Clarkson EGO STATES – parent, adult, child P A C P A C ATTACHMENT John Bowlby ‘primary care-giver’ (usually mother) – juvenile Perceived threat proximity-seeking/maintenance Play & Transitional Space D.W. Winnicott Attachment strategy/style • Synonym for disorder – especially anxious borderline personality disorder • Predispose to disorder • Affects illness behaviour and therapeutic relationship • May be a complicating independent factor (e.g. social isolation) A four-category model of adult attachment view of self positive positive negative secure preoccupied autonomous enmeshed low view of others Avoidance negative dismissing fearful detached ? unresolved high ? disorganised ? incoherent low high anxiety Bartholomew & Horowitz, 1991; Brennan et al., 1998 Outline 2 – Assertive Outreach • History • Principles & Practice • Outcomes • where next? Deinstitutionalisation • Massive closures of mental health beds • ‘community care’ • Problems transfer from hospital site to community • Keeping patients out of beds is priority Oppositional Model of Psychiatry • Patient thinks they’re ill – not • Patient doesn’t think they’re ill – must be • Patient wants medication – refuse • Patient doesn’t want medication – insist • Patient wants admission – refuse • Patient refuses admission - coerce Homicides • Patients move from place to place, service to service • Separate services/records: health & social care • Information does not follow patient • Patients disengage • Patients stop medication • medication alone is not enough • Poor team work, staff don’t follow procedures Nb victimisation; ISoS 25% lost to f/u esp. male slow onset Media & politicians Psycho axe murderer innumerate consumers/voters Something must be done Foreign prophets • Stein & Test (1980) Assertive Community Treatment • Discharge from publicly funded bin: to community with no funded health care to community with limited social welfare • No rehabilitation programmes • High relapse/readmission rate Answers • Care Programme Approach • Christopher Clunis report (Ritchie,1994) • Cochrane Review 1998 recommends ACT • MH Policy Implementation Guide 2001 eligibility criteria • Adult • Severe mental illness • Failure of standard care - revolving door - disengagement/treatment resistant - multiple complex needs • High risk • depends partly on what else is available EXIT criteria ? PRACTICAL ASPECTS • Skill mix – different disciplines including medic • Caseload capped 10-15 per care co-ordinator • Critical mass – sufficient size for team • Extended hours • Strong communication internal and external STAFF ATTITUDES • Team player • ‘can do’ • Flexible • Low EE • Doesn’t flap GREY AREAS • Evening / 24 hour working • ‘whole team approach’ • Application to rural areas Cochrane Standard Rehab Remain in contact more + = Fewer admissions + + Less time in hospital + + Better accommodation + Better employment + Better patient satisfaction + Better mental state = = Better social function = = More living independently More cost effectiveness Empty cell = lack of data + AO better = no difference ≈ no clear difference Case MM + + ≈ ≈ Current evidence Very mixed Issues • fidelity • duration of study • difference from ‘standard’ service Generally • better engaged • more satisfied • ? IP – more likely if previous use high if faithful to model: daily meet, MDT, focus, h.v. • therapeutic relationship engagement fewer admissions (new patients) After AO/ACT? • UK services very varied • FACT = Flexible/functional ACT = larger caseload (15-25) = step up/down within team = zoning/RAG - ragging • How the poor die – Orwell • Ward 6 – Chekhov • Notes from the Underground Part I the Underground - Dostoevsky Specialist assessment and treatment of patients with chronic and severe mental disorders Knowledge • • • • • clinical presentations and natural history of patients with severe and enduring mental illness role of rehabilitation and recovery services concept of recovery concept of quality of life and how it can be measured Awareness of disability/housing benefits Skills • • • • • Maintain hope whilst setting long term, realistic goals Develop long-term management plans Act as patient advocate in negotiations with services Demonstrate skills in risk management in chronic psychiatric disorders Demonstrate skills in pathway care management Attitudes demonstrated through behaviours • • • • Treat each patient as an individual Appreciation of the effect of chronic disease states on patients and their families Develop and sustain supportive relationships with patients with severe and enduring mental illness Appreciation of the importance of co-operation and collaboration with primary healthcare services, social care services, and non-statutory services Communication • • • • • • Effective communication with patients, relatives and colleagues in a manner that facilitates information gathering and the formation of therapeutic alliances structure the clinical interview to identify the patients concerns and priorities, their expectations and their understanding Demonstrate interviewing skills Solicit and acknowledge expression of the patients’ ideas, concerns, questions and feelings Demonstrate respect, empathy, responsiveness, and concern for patients understanding of the need for involving patients in decisions, offering choices, respecting patients’ views Clinical teamwork • • • • • • Understanding of the roles and responsibilities of team members Understanding of the roles of primary healthcare and social services Communicate and work effectively with team members Show respect for the unique skills, contributions and opinions of others Recognise and value diversity within the clinical team Be conscientious and work cooperatively References BARTHOLOMEW K, HOROWITZ LM. (1991) Attachment styles among young adults: a test of a four category model. J Personality Soc Psychology 61: 226-244. BERNE, E. (1968) Games People Play: The Psychology of Human Relationships. Penguin Books: London. BERRY, K. et al. (2007) A review of the role of adult attachment styles in psychosis. Clinical Psychology Review 27: 458-475 BOWLBY J. (1977) The Making and Breaking of Affectional Bonds 1 Aetiology & Psychopathology in the Light of Attachment Theory. British Journal of Psychiatry 30: 201210. BOWLBY J. (1977) The Making of Breaking of Affectional Bonds 2 Some Principles of Psychotherapy. British Journal of Psychiatry. 130:421-431. BRENNAN, K.A. et al (1998) Self-report measurement of adult attachment – an integrative overview. In SIMPSON, J.A. & RHOLES, W.S. (eds) Attachment Theory and Close Relationships. New York, NY: Guilford Press BURNS T. & FIRN M. (2002) Assertive Outreach in Mental Health. Oxford University Press: Oxford BURNS T. et al (2007) Use of Intensive Case Management to Reduce Time in Hospital in People With Severe Mental Illness: Systematic Review & Meta-regression. British Medical Journal 335 336-?. BURNS T. (2010) The rise and fall of assertive community treatment? International Review of Psychiatry, 22: 130-137 CLARKSON P. (1987) The Bystander Role. Transactional Analysis Journal 17: 82-87. COPELAND M. E. Wellness Recovery Action Plan. Website: http://www.mentalhealthrecovery.com DEPARTMENT OF HEALTH (2001) The Journey to Recovery – The Government’s Vision For Mental Health Care. London: Stationery Office. Also available on http://www.dh.gov.uk/en/publications&statistics/publications/publicationspolicy&guidance/dh_4002700 DEPARTMENT OF HEALTH (2001) The Mental Health Policy Implementation Guide. London: Stationery Office (available on http://www.dh.gov.uk/en/publications&statistics/publications&statistics/publications/publicationspolicy&guidance/dh_4009350 (Chapter 4 pp 26-42 refer to Assertive Outreach) DRAKE, R. (2010) Attachment theory in psychiatric rehabilitation. Advances in Psychiatric Treatment 16: 308-315 FAKHOURY W. K. H. et al. (2007) Be Good to Your Patient: How the Therapeutic Relationship in the Treatment of Patients Admitted to Assertive Outreach Affects ReHospitalisation. Journal of Nervous & Mental Disease 195: 789-791. FIRTH, R. (1961) Suicide and risk-taking in Tikopia Society. Psychiatry 24: 1-17. GAMBLE C. & BRENNAN G. (Eds). (2000) Working with Serious Mental Illness: A Manual For Clinical Practice. Baillière Tindall: Edinburgh. HOLMES J. (1993) John Bowlby & Attachment Theory. Routledge : London. HOPPER, K. et al. (2007) Recovery from Schizophrenia: an international perspective. Oxford: Oxford University Press KARPMAN, S. (1958) Fairytales and Script Drama Analysis. Transactional Analysis Bulletin 7: 39-43. (available on http://www.itaanet.org/tajnet/articles/karpman01.html) KILLASPY, K. (2008) Assertive Community Treatment in Psychiatry. British Medical Journal 335: 311-2. MA, K. (2006) Attachment Theory in Adult Psychiatry. Part 1: Conceptualisations, Measurement & Clinical Research Findings. Advances in Psychiatric Treatment. 12: 440-449. MA, K. (2007) Attachment Theory in Adult Psychiatry. Part 2: Importance to the Therapeutic Relationship. Advances in Psychiatric Treatment. 13: 10-16. MARSHALL, M., LOCKWOOD, A (1998) Assertive Community Treatment for People with Severe Mental Disorders. Cochrane Database of Systematic Reviews, Issue 2, Article number CD001089. DOI-10.1002/14651858.CD001089 (available on http://www.cochrane.org/reviews/en/ab001089.html). PERKINS R. E & RAPPER J. M. (1996) Working Alongside People With Long-Term Mental Health Problems. Nelson Thornes: Cheltenham. PRIEBE, S. et al. (2005) Process of disengagement and engagement in assertive outreach patients: qualitative study. British Journal of Psychiatry 187: 438-443. PROCHASKA, J. O., NORCROSS, J.C. & DICLEMENTE, C. C. (2002) Changing for Good: A Revolutionary Six Stage Programme for Overcoming Bad Habits and Moving Your Life Positively Forward. New York: Quill-Harper Collins. RAPP, C. A. & GOSCHA, R. J. (2006) The Strengths Model: Case Management with People with Psychiatric Disabilities (second edition). New York: Oxford University Press. RITCHIE J. H, DICK D. & LINGHAM, R. (1994) The Report of the Inquiry into the Care & Treatment of Christopher Clunis. London: HMSO. ROBERTS G., DAVENPORT S., HOLLOWAY F. & TATTAN T. (2006) Enabling Recovery: the Principles and Practice of Rehabilitation Psychiatry. Gaskell: London. SHEPHERD G, BORDMAN J, & SLADE M, (2008) Making Recovery a Reality. London: Sainsbury Centre for Mental Health. Also available on http://www.scmh.org.uk/pdfs/making_recover_a_reality_policy_paper.pdf STEIN, L.I. & TEST, M.A (1980) Alternative to Mental Hospital Treatment. 1: Conceptual Model, Treatment Programme, & Clinical Evaluation. Archives of General Psychiatry. 37: 392-397. STEWART I. & JOINES V. (1987) T.A. Today: A New Introduction to Transactional Analysis. Life Space. Publishing: Nottingham. TEST, M.A. & STEIN, L.I. (1980) Alternative to Mental Hospital Treatment. 3: Social Cost. Archives of General Psychiatry. 37: 409-412. WALSH et al. (2003) Prevalence of Violent Victimisation in Severe Mental Illness. British Journal of Psychiatry 183: 233-238. WARNER, R, (2003) How Much of the Burden of Schizophrenia is Alleviated by Treatment? British Journal of Psychiatry 183: 375-376. WARNER, R. (2004) Recovery from schizophrenia: psychiatry and political economy. Third edition. Hove: Brunner-Routledge. WHOMSLEY, S. (2009) Team case formulation. In Cupitt, C. (ed.) Reaching out: the psychology of assertive outreach. Routledge. WORLD HEALTH ORGANISATION (1980) International Classification of Functioning, Impairment, Disabilities and Handicaps. WHO: Geneva WORLD HEALTH ORGANISATION (2001) International Classification of Functioning, Disability and Health. WHO: Geneva Other reading Ward 6 by Anton Chekhov Notes from the Underground by Fedor Dostoevsky How the Poor Die by George Orwell Thank you