Supporting community clinicians to work proactively with psychosis: lessons learnt in the UK
Catherine Gamble, Consultant Nurse
Aim
- Historical overview
- Review principles learnt
- What kind of outcomes
- Sustain quality care beyond change agendas
Thorn Initiative
Dr Jim Birley
From left to right: Eric Davis, Keith Coupland; Tim Bradshaw; Malcolm Rae; Lorraine Rayner; Prof. Julian Leff; Tony Buttterworth ; Dr Jim Birley; Madaline O’Carroll; John McGovern; Cliff Roberts; Catherine Gamble
Supported by charitable funds
Aim:
- Challenge assumptions & enhance knowledge
- Resuscitate nurses role and function
- Promote collaborative working styles
- Address change agenda
Main subject areas:
- Case management and assessment,
- Family intervention
- Psychological management of symptoms
Why a need for new journey?
- Context of community care changing
- Workforce needed to adapt to new service concepts
- Adopt different roles from those previously held
- Quality of education determining the quality of treatment received
Programme outline & structure
Would strategy be effective?
- Simple Naturalistic Study
- Trainees - recruited to develop skills and employ psychosocial interventions with 4 clients with SMI
- Clients and families selected from trainees existing case loads
- Standardised measures to assess clients clinical and social outcomes: KGV symptom scale; PSE and SFS
- Independent evaluation
- First of its kind
Influence of training on skills
Influence of training on practice
Key Findings
- Patients showed statistically significant and worthwhile reduction in severity of symptoms.
- Positive improvements in positive, negative and affective symptoms
- Significant, although considerably smaller improvement in social functioning
- Practitioners could be trained to deliver psychosocial treatments
Community based care growing
- Assertive Outreach Teams
- 24 hour Crisis Resolution and Home Treatment Teams
- Early Intervention Services
- Flexible working: skills of team determined by patient need
- Specialist areas substance misuse, employment workers
- High role preparation need
Factors affecting implementation
- Lack of time
- Difficulty with integration
- Availability of supervision
- Daily demands of the service
- Multiple priorities
- Short term thinking by management
- Responding to crises
- Lack of understanding from colleagues
Growth in Number of Teams
It shouldn’t have be about finding bright lights in dark tunnels
The Trek:
- Practical challenges
- Personal prejudices
- Horizontal scepticism
- Language
- Methodology paradigms
- Attitudes, skills and knowledge
Frameworks & principles
- Stress vulnerability
- Attributions
- Rogerian characteristics
The Trek summary
- Positive, partnership attitude
- Good communication skills
- Team players
- Confidence in handling conflict and organisational change
- Openness to reflect on own practice
- Skills in applying EB interventions and understanding of family systems
- Insider practice developers
Local Implementation Strategy
Cascading Development Model
Recovery paradigm
Members of the family can support one another but they can’t recover for one another:- Discovery /Denial
- Recognition/Acceptance
- Coping
- Personal and Political Advocacy
- Hang in there through the healing process
- Emotional reactions are natural and do not imply there is something wrong
- Roll with phases of self discovery, renewal and growth
- Use hopeful language by providing alternatives to the maintenance approach
- Develop an optimistic, normalised inclusion strategy
- Reframe intervention
- Back door approach
- Forward-looking, activity based
- Encouraging, celebrating and acknowledging
- Pragmatic, creative engagement strategy
- Family approval & relapse prevention plan
Service Recommendations
- Develop operational development guides
- Create practice development environments
- Consider backfill monies for seconded students
- Review case load sizes
Training Recommendations
- Evaluation of training– agree methods to audit outcomes and quality
- Monitor competencies during and post training (including trainers)
- Train supervisors and service managers
Factor in:
- Controlled studies to measure impact, particularly from consumers perspective
- Follow up studies to ascertain preservation of knowledge, skills and attitudes
Conclusion
- Gained respect and are valued by service users and their families
- Positive, partnership attitude
- Strong leaders and good team players
- Confidence in handling conflict and organisational change
- Evidence based tools
- Coaching within recovery paradigm: attractive to younger generation provides a focus for the future
- Insider practice developers
References
- Brooker, C., Brabban, A., (2004) Measured Success: A scoping review of evaluated PSI training for people with serious mental health problems. NIHME/Trent WDC
- Gamble, C Family intervention (2007) Psychiatry Vol:6:9 367-372
- Gamble, C (2006) The zoning revolution. Mental Health Practice vol. 10 no.4 14-17
- Leff, J. (2000) Commentary. Advances in Psychiatric Treatment 6: 250-251
- Ryrie, I et al (1997) Zoning: a system for managing case work and targeting resource in CMHT’s. Journal of Mental Health 65, 515-523
- www.thorn-initiative.org.uk