Download slides - ESTD Training Conference

Making Inpatient
Environments more
Dissociation Friendly
Dr Mel Temple
Consultant Psychiatrist & Psychotherapist
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Making Inpatient Environments more
Dissociation Friendly
Workshop – you’ll be doing some work!
• Outline:
– Background
– Challenges
– Considerations
– Training
– Our Experience & Service User / staff video
– Round-up
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Making Inpatient Environments more
Dissociation Friendly
• Background
– Myself - consultant psychiatrist & psychotherapist (accredited
IPT / EMDR), background in trauma work & complex cases,
community & inpatient management
– The Retreat – Quaker charitable mental health organisation
developed in response to asylum care and pioneers of “humane”
treatment approaches to mental health with relationships,
compassion, collaborative care and a sense of community at the
centre.
– The Unit - New unit to be developed from closure of old 12
bedded “complex cases” unit which had become “too high risk”
and concerns raised on external scrutiny.
– The NHS Placement Landscape – High complexity (c-PTSD /
dissociation / personality disorder / eating disorder), high risk,
often detained already multiple failed in-patients / out-patient
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approaches
Making Inpatient Environments more
Dissociation Friendly
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Making Inpatient Environments more
Dissociation Friendly
• The Challenges - Brainstorming
– Why do the patients need inpatient care?
• Community approaches are in general considered
the best approach so why might you consider
inpatients?
• Acute units vs specialist units
– What difficulties do patients with dissociative
disorders experience on inpatient units?
– What difficulties do staff experience in
managing these patients?
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Making Inpatient Environments more Dissociation Friendly
• Why might patients • Acute unit
need inpatient care?
– Acute crisis
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Safety
– No other option – funding
issues
Distress levels
– Lack of skills needs
Stuck – revolving door
addressing as can be more
“untreatable”
traumatising
Unable to manage
outpatient treatment • Specialist Unit
– Planned admissions
– Funding difficulties /
process
– Best place for treatment –
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only 1 unit!
Making Inpatient Environments more Dissociation Friendly
Service User Experiences
Staff Experiences
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• Experience of Helpless /
hopeless around knowing
what to do
• Anger – rejection
• Pull back
• Sense of incompentence
• Activation of own issues
• Lack of structure or
support around staff to
assist them
• Reliance on the use of
medication
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Invalidating
“told off”
Told manipulative, lying
Labelled
Controlled
Feel helpless
Disbelieved – trauma
secrecy cycle continued
• Re-traumatised
• May be further victimised
• Over medicated
Making Inpatient Environments more
Dissociation Friendly
• Considerations…more brain storming!
– Environmental Aspects
– Staffing
• Levels, Attributes, Training, Ongoing support
– Unit Programme Aspects
– Use of MHA? MCA?
– Use of Medication?
– Service user aspects
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Making Inpatient Environments more
Dissociation Friendly
• Environment
Quiet, calm, cosy
single sex,
Own room & facilities
As many choices as
possible within
presenting risk
Clear expectations &
boundaries
Outside space
animals
• Staffing
high ratio staff:patients
Characteristics –
warmth, empathy,
compassion,accepting,
validating & curious
stance
Personable
Ability to be consistent
and work to appropriate
boundaries
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Making Inpatient Environments more Dissociation Friendly
• Programme
• MHA / MCA
Underpining relational
framework evident across
the team
Individualised & group
Approaches to assist with
difficulties
Skills training & promotion
of recovery focus
Integration of any trauma
work –collaborative working
Ongoing Training and
supervision to support this
Consideration to the supportive
role MHA can play in assisting
adult to regain control / manage
risk within system
Difficulties of capacity framework
in state shifting especially adult
self state presentations
Protections within the MHA
framework.
• Medication
Judicious and appropriate use –
little evidence. Relational support
should be first line
Treatment of comorbidities
Role to review & take off meds
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Making Inpatient Environments more Dissociation Friendly
• Service User
Single sex
How to manage history of
violence / aggression &
create safe environment –
can you mix those with
Flight / freeze vs fight
responses?
Motivation to engage &
recover?
Level of understanding /
acceptance of system?
• Others
Active risk history &
agreement on how to
manage
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Making Inpatient Environments more
Dissociation Friendly
• Training – What training to do?
• What training do you think most staff (including doctors)
have had in trauma and dissociative presentations?
• What do you think staff understand about the symptoms
and difficulties these patients might experience?
• What skills training do you think staff will have had around
support to these symptoms?
• How do you match training across the different staff
groups?
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Making Inpatient Environments more
Dissociation Friendly
• What Training? What is available?
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ESTD 4 day foundation training
PODS new clinician training courses
In- house around PTSD etc.
Other general training – Attachment, Structured clinical
management, KUF
• Clinical Skills Coaching training – flashback
management, grounding, chain analysis, interpersonal
skills (relationships, mentalising, communication),
emotions management (allowing experience,
identification, tolerating, managing)
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Making Inpatient Environments more
Dissociation Friendly
ESTD Foundation Course
• This four module ESTD-UK Foundation course developed and
delivered in collaboration with First Person Plural.
• It takes place over four days, usually as 2 x 2 consecutive days
scheduled about 1 month apart.
• The course as a whole is primarily for qualified counsellors,
psychotherapists, clinical psychologists and other professionals
working therapeutically with chronically traumatised clients who
have a (diagnosed or not yet recognised) complex dissociative
disorder.
• Participants attending all four modules will have gained a solid
foundation on which to build their continuing professional
development in a critical knowledge and skills set for recognising
and working effectively with the many highly dissociative chronically
traumatised individuals who present in NHS mental health and other
therapy settings.
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Making Inpatient Environments more
Dissociation Friendly
• Module 1: Understanding dissociation & complex dissociative
disorders
Trainers : Melanie Goodwin & Kathryn Livingston (First Person
Plural)
• Module 2: Developmental origins of dissociation in childhood
Trainer: Dr Renee Marks, Consultant therapist specialising in
children & adolescents
• Module 4: Resources & resourcing: using a body-centred
approach to working with trauma and dissociation
Trainer: Lyn Terry-Short, Chartered Psychologist with 20 years’
experience in NHS
• Module 3: Assessment & Treatment Approaches
Trainer : Dr Mike Lloyd, Consultant Psychologist
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Making Inpatient Environments more
Dissociation Friendly
• The Kemp Experience
• 8 bedded
• Homely modified risk environment
• All women, Focus on C-PTSD / Dissociation / PD / Cormorbidities
including eating disorders & OCD
• Specific exclusion to antisocial PD / history of violence or
aggression to others in last 6 months
• High staffing ratio to allow for relational psychological approaches
as first step
• Underpinning model to the unit – Structured Clinical Management
– Generalist
– Relational & attachment based (1:1 key worker)
– Curious & validating stance – look beyond the behaviour to understanding the
reason for it
– Focus on risk reduction & skills & resilience building
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Making Inpatient Environments more
Dissociation Friendly
• The Kemp Experience
• Programme aspects – SCM problem solving, Emotions Group, CFT
Compassionate mind Group, IPT – Interpersonal Skills Group, Life
Skills
• Recruitment – focus on relational interaction & attitudes alongside
experience, service user involvement in recruitment
• Training & Supervision
– Training package before opening
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Intro aspects – PD, PTSD, Eating Disorders, Skills works – IPT / CFT / DBT / CBT
ESTD 4 days
SCM 2 days
KUF Personality disorder
Boundaries, Risk assessment & management
– Ongoing weekly skills coaching
– Weekly case formulation meetings
– Weekly group supervision
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Making Inpatient Environments more
Dissociation Friendly
• Service User & Staff Video
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Making Inpatient Environments more
Dissociation Friendly
• The Kemp Experience
What has gone well?
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Environment (with one exception…..)
Attitude and approach of staff
Upskilling of staff
Ability to hold difficult experience
Ability to retain a curious, non judgemental, validating stance
Appropriate & low level use of medication
Collaborative Use of the MHA
Positive Risk Taking
Extremely positive response from service users & positive outcomes
measures
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Making Inpatient Environments more
Dissociation Friendly
• The Kemp Experience
What has not gone so well?
-Staff turnover
Marmite speciality area – learning as to recruitment
Risk management aspects – high stress
Unit & Organisational operational aspects
Job progression offers
-Suspicious & negative response from other clinicians
-Organisations comfort around risk given CQC reports etc
-Lack of contained outside space
-Lack of large kitchen / diner to allow for self catering
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Making Inpatient Environments more
Dissociation Friendly
• Questions?
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